
Class _Zl f/ 
Book._ 



Gopiglitfl?- 



/**:■' :*■ "O 



COPYRIGHT DEPOSIT. 



DISEASES OF THE EAR 

IN CHILDHOOD 



BY 



DR. GUSTAV ALEXANDER 

VIENNA 



TRANSLATED BY 

ARTHUR J. BEDELL, M.D., 

CLINICAL PROFESSOR OF OPHTHALMOLOGY, ALBANY MEDICAL COLLEGE 



ISO Illustrations, 9 Full Page Inserts in Color and Black, and 18 Colored Text Illustrations 



SECOND EDITION 




PHILADELPHIA y LONDON 
J. B. LIPPINCOTT COMPANY 



nil 



/v\ 



Copyright, 1914 ' 
By J. B. Lippincott Company 

Copyright, 1917 
By J. B. Lippincott Company 



Electrotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U.S.A. 






dUL -7 1917 

(57787 



I 



Preface 



Almost every year new text-books on Otology are published, de- 
scriptive of the rapid progress and status of this branch of medical 
science. The pathological conditions which occur in infancy and child- 
hood are described briefly, but there is no characteristic and exhaustive 
description of the anatomical, clinical, and therapeutic peculiarities, which 
are important factors in the child's ear. 

The publication of the present volume was prompted by a desire 
to fill this need, and I willingly complied with the request of the editors 
of "The Diseases of Children" to write a supplementary volume deal- 
ing with the affections of the ear in infancy and childhood. 

The many peculiarities of childhood impart a special character to 
the affections of the ear, and give rise to pathological pictures peculiarly 
their own. 

The consideration of this fact was a sufficient incentive to under- 
take the work, but other factors rendered its execution imperative, 
namely, the great frequency of oral affections in infancy and childhood, 
and their importance in the mental and physical development of the 
young. 

It was difficult, however, to decide upon the amount of detail in 
which the various sections should be presented, for, if this volume were 
to adapt itself to the requirements of the pediatrist in accordance with 
the former ideas on the subject of juvenile otology, it would have been 
necessary to condense the available material. This, however, would 
have materially interfered with the scientific treatment of the questions 
involved. 

Feeling that the requirements of the modern pediatrist would not 
be served by a simple compilation of therapeutic indications, I decided 
to include all anatomical, clinical, and diagnostic facts, aside from the 
therapeutic armamentarium, which represent the present knowledge of 
our specialty. Bearing the practical importance of the latter in mind, I 
have endeavored to satisfy the demands of the general practitioner, so 
that he may obtain a clear understanding of the pathological pictures, 
of their causes and development, of the therapeutic measures to be 
adopted, and of the correct interpretation of difficult and complicated 
conditions which should be referred to the otologist for rational treat- 
ment. It need not be specially emphasized that a correct procedure on 
the part of the attending physician is of extreme importance in otological 
complications. 

iii 



iv PREFACE 

The child's ear differs materially from that of the adult in various 
particulars, which are not only of theoretical but also of clinical import- 
ance, and which for purposes of diagnosis and treatment should not be 
neglected. For this reason the anatomy of the child's ear had to be 
described in detail. At the same time, this chapter has been so arranged 
as to facilitate the study of the text when comparing it with anatomical 
preparations. 

In regard to the physiology of the ear, I have confined myself to 
the most necessary details. The theory of hearing and the physiology 
of the vestibule have only been discussed in so far as is necessary for a 
clear understanding of the clinical methods of functional tests. 

In the section on clinical methods of examination, I have described 
those which are in use in my own department, where I have always at- 
tached the greatest value to combining exact methods with rapid and 
convenient application. 

In the arrangement of the clinical material, I have followed the 
method I am in the habit of using in my clinical lectures. In discussing 
the affections of the labyrinth and the extra- and endocranial affections 
of the ear, I have selected that method of grouping which has proved to 
be necessary in keeping step with the progress of modern otology. The 
oral affections of infancy have been given special consideration. 

The increased interest which has been extended to juvenile oral 
conditions in modern times has been followed by astonishing results in 
the education and care of the deaf-mute. Accordingly, it was necessary 
to discuss deaf-mutism, the education of the deaf-mute and those with 
difficult hearing, as well as the question of school physicians. Deafness 
in cretins, endemic deafness, and constitutional oral affections have been 
treated in a special chapter. The book also deals with a number of oral 
affections which, up to a short time ago, were regarded as diseases of 
the adult; they include various forms of labyrinthine deafness and oto- 
sclerosis, the foundation of which may have been laid in childhood or 
in utero, as has been shown by anatomical findings. 

Diseases of the ear occurring in conjunction with infectious diseases 
are only mentioned, so far as their characteristic facts are concerned, 
while the details of the pathological pictures and the. local treatment are 
dealt with in preceding chapters. 

The most important affections to be discussed are those of the 
middle ear, especially suppurative inflammation and its complications. 
The extra- and endocranial otogenous affections are, therefore, arranged 
as independent sections attached to other chapters. Only such operative 
measures have been mentioned as are at present in use, while I considered 
it indispensable to include the important question of after-treatment. 

Special care has been exercised in selecting the illustrations. The 



PREFACE v 

wealth of illustrations of the anatomical section, including the diagrams, 
will no doubt contribute to a better understanding of the descriptive 
text. The majority of the illustrations have been made from my own 
preparations and cases, or drawn in accordance with my own clinical 
observations by the medical draughtsman, Carl Beck, in a very satis- 
factory manner. A number of illustrations referring to clinical findings 
have been supplied by Dr. Oskar Binesi; others, among which are the 
schematic sketches, have been drawn by myself. 

Dr. Gustav Alexander. 

Vienna. 



TRANSLATOR'S PREFACE 



No recent work has offered so much of value to the general prac- 
titioner and children's specialist as this by Professor Alexander of 
Vienna. The numerous illustrations assist in the thorough under- 
standing of the many ear lesions and should make a strong appeal to 
the pediatrist who sees the conditions in daily work and to the otol- 
ogist because of the exhaustive, authoritative statements relative to the 
common and more obscure conditions. 

In this translation no additional notes have been added, the original 
text being complete, so that in presenting it to the English reading 
public a favorable reception is anticipated. 

Arthur J. Bedell, M.D., 

Clinical Professor of Ophthalmology, 
Albany, N. Y. Albany Medical College. 



Table of Contents 

VOLUME VI. 



PAGE 

I. Anatomy of the Ear 1 

I. The Temporal Bone 3 

II. Changes of the Temporal Bone during Growth 6 

III. The External Ear v 9 

IV. The Middle Ear 13 

V. The Internal Ear 34 

I. Histological Structure of the Nerve-end Cells of the Labyrinth 38 
II. The Osseous Labyrinth (Osseous Capsule) and the Perilym- 
phatic Tissue (Perilymphatic Capsule of the Labyrinth) .... 41 

III. Topography of the Nerve-end Places of the Labyrinth 44 

IV. Topography of the Internal Ear 44 

V. Eighth Nerve 46 

II. Physiology of the Ear 48 

The Theory of Hearing. The Physiology of the Sound-Conducting Apparatus 49 

The Sense of Hearing in the New-born 50 

The Physiology of the Static Labyrinth (Apparatus of the Semicircular 

Canals and Vestibule) 51 

Theories on the Functions of the Labyrinth 52 

The Functions of the Normal Apparatus of the Semicircular Canals and 

Vestibule at Physical Rest and in Motion 53 

III. Examination of the External Auditory Canal and Middle Ear 55 

1. Otoscopic Examination 55 

2. Methods of Cleansing the External Canal and the Tympanic Cavity. ..... 55 

3. Normal Otoscopic Picture of the External Auditory Canal and Tympanic 

Membrane. Otoscopy of the Tympanic Cavity 56 

IV. Methods of Examining the Middle Ear 59 

1. Examination of Mobility of the Tympanic Membrane and of the Contents 

of Tympanic Cavity 59 

2. The Valsalva Test 59 

3. Politzer's Method (Air Douche, Insufflation after Politzer) 60 

4. Catheterization 61 

V. The Functional Hearing Test 64 

I. Determination of Auditory Acuity in Relation to Speech; the Acoumeter 64 

Test Arrangement for Speech 66 

II. Tuning-fork Test 69 

A. General Tuning-fork Tests 70 

B. Qualitative Test by Tuning Fork 75 

C. Quantitative Test by the Tuning Fork 79 

vii 



viii TABLE OF CONTENTS 

III. Test of Cranial bone Conduction by Noises 80 

IV. Demonstration of Unilateral Deafness 80 

V. Demonstration of Simulated Hearing Insufficiency, Simulated Unilateral 

and Bilateral Deafness 83 

VI. Functional Examination of the Semicircular Canals and the Vestibular 

Apparatus 86 

1. Labyrinthine Nystagmus and the Methods of its Observation 86 

2. Spontaneous Labyrinthine Nystagmus 87 

3. Labyrinthine Nystagmus and Vertigo as Differentiated from the Other 

Forms of Nystagmus and Vertigo 87 

A. Examination of the Semicircular Canals 90 

B. Methods of Examination of the Semicircular and Vestibular 

Apparatus 92 

C. Methods of Testing the Vestibular Apparatus 93 

VII. Local Anesthesia of the Ear 97 

VIII. Diseases of the Concha and the External Auditory Meatus 99 

1. Congenital Anomalies of Development of the Concha and the External 

Auditory Meatus 99 

2. Congenital Atresia of the External Auditory Canal 102 

3. Acquired Deformity of the Concha and External Auditory Meatus; 

Acquired Position Anomalies of the Concha 106 

4. Acquired Atresia of the External Auditory Meatus 108 

5. Traumatic Injuries of the Concha and the External Auditory Meatus, 

Including Cuts and Bites Ill 

6. Serous Perichondritis 113 

7. Phlegmonous Perichondritis. Acute Purulent Perichondritis 114 

8. Foreign Bodies in the External Auditory Duct 116 

9. Otitis Externa Eczematosa (Eczema of the Concha and External Auditory 

Meatus) 121 

10. Otitis Externa Furunculosa; Otitis Externa Follicularis (Furuncle of the 

Auditory Duct) 125 

IX. Affections of the Middle Ear 128 

I. Traumatic Injuries of the Tympanic Membrane 128 

1. Direct Rupture of the Tympanic Membrane 128 

2. Indirect Ruptures of the Tympanic Membrane 129 

11. Inflammatory Infections of the Tympanic Membrane 132 

1. Acute Inflammations of the Tympanic Membrane (Myringitis 

Acuta) 132 

2. Subacute and Chronic Inflammation of the Tympanic Mem- 

brane (Myringitis Subacute and Chronica) 134 

III. Catarrhal Affections of the Middle Ear 135 

IV. The Chronic Adhesive Process 142 

V. Simple (Serous) Acute Inflammation of the Middle Ear (Otitis Media 

Acuta Simplex) 146 

VI. Acute Purulent Inflammation (Ulceration) of the Middle Ear (Otitis 
Media Suppurativa (Perforativa) Acuta); Tympanites Purulenta 
Acuta 151 



TABLE OF CONTENTS ix 

VII. Acute Inflammation of the Middle Ear in Infants and Young Children 

(Acute Infantile Otitis) 159 

VIII. Acute Purulent Mastoiditis (Osteoperiostitis of the Mastoid Process) . . . 166 
IX. Chronic Middle-ear Suppuration 179 

1. Simple Chronic Middle-ear Suppuration 179 

2. The Surgical Forms of Chronic Middle-ear Suppuration 190 

X. Affections of the Capsule of the Labyrinth 222 

I. Exostoses of the Lateral Wall and Obliteration of the Window of the 

Labyrinth 222 

II. Acute Suppurative Paralabyrinthitis 223 

III. Fistulae of the Labyrinth 224 

IV. Otosclerosis 227 

XL Affections of the Internal Ear 234 

I. Congenital Anomalies of the Labyrinth 234 

1. Congenital Deafness Due to the Labyrinth 234 

2. Congenital Affections of the Static Labyrinth 237 

3. Congenital Deafness 238 

II. Inflammatory Affections of the Labyrinth 256 

1. Acute Suppurative Paralabyrinthitis with Fistula Formation 262 

2. Labyrinthitis Serosa 264 

3. Circumscribed and Diffuse Uncomplicated (Simple) Suppuration 

of the Labyrinth 265 

4. Complicated Diffuse Suppuration of the Labyrinth 270 

XII. Extracranial Affections of the Ear 276 

I. Subperiosteal Mastoid Abscess 276 

II. Osteoperiostitis and Subperiosteal Abscesses of the Temporal Squama 

and the Zygomatic Process 281 

III. Fistula Formation in the Osseous Auditory Canal 283 

IV. Otogenic Descending Abscesses of the Submaxillary Region 286 

V. Descending Abscesses along the Eustachian Tube 286 

VI. Otitic Descending Abscesses of the Neck and Suboccipital Otogenic 

Suppuration 287 

XIII. Endocranial Otogenic Affections 293 

I. Pachymeningitis Externa and Extradural Abscesses 293 

II. Otitic Thrombophlebitis, Otogenic Pyaemia, Bacteremia, and Toxaemia 

(Septicaemia) 301 

Bulbus Thrombosis 314 

Ligation of the Jugular Skin Fistula of the Jugular 316 

Pyaemic Metastases 319 

III. Otitic Serous Meningitis 325 

IV. Circumscribed Suppurative Pachyleptomeningitis and Intrameningeal 

Abscess 327 

V. Acute Diffuse Suppurative Otogenic Pachyleptomeningitis (Meningo- 

encephalitis) 331 

VI. Otogenic Tuberculous Meningitis 335 



x TABLE OF CONTENTS 

VII. Otogenic Abscess of the Temporosphenoid Bone 337 

VIII. Otogenic Cerebellar Abscesses 347 

Lumbar Puncture and its Significance in Otology 355 

XIV. Traumatic Injuries of the Organs of Hearing 361 

XV. Malignant New-formations of the Ear 363 

XVI. Affections of the Ear in General Diseases 365 

I. Affections of the Ear in Diseases of the Blood and the Blood-forming 

Organs 365 

II. Constitutional Ear Diseases 366 

1. Affections of the Ear in Lymphatic Constitution and Rhachitis. . 366 

2. Diseases of the Ear in Endemic Cretinism 367 

III. Affections of the Ear in Acute Infectious Diseases 375 

1. Affections of the Ear in Scarlet Fever and Measles 376 

2. Affections of the Ear in Diphtheria 380 

3. Affections of the Ear in Epidemic Parotitis (Mumps) 381 

4. Ear Affections in Typhoid Fever 382 

5. Ear Affections in the Course of Influenza (La Grippe) 385 

6. Meningitic (Meningogenic) Labyrinthitis (Meningic Deafness) . . 386 

7. Affections of the Ear in the Other Acute Infectious Diseases 388 

IV. Ear Affections in Chronic Infectious Diseases 389 

A. Tuberculous Diseases of the Ear 389 

B. Syphilitic Affections of the Ear 401 

XVII. Impaired Hearing during School Life. The School Otologist 407 



List of Illustrations 

VOLUME VI. 



PAGE 

1. Temporal Bone of the New-born 1 

2. Vertical Frontal Section through the Temporal Cavity 2 

3. Petrous Portion of the Tympanum in a Six-months-old Infant 4 

4. Posterior Surface of the Petrous Bone in a Fourteen-year-old Child. . 4 

5\ Surgically Important Parts of the Inferior Surface of the Temporal 

6 J Bone 4 

7. Medial Wall of the Tympanic Cavity of the New-born 5 

8. Posterior Surface of the Petrous Bone 6 

9. Persisting Gap in Ossification of the Tympanum 7 

10. Lateral Surface of Temporal Bone in a One-year-old Child 8 

11. Right Petrous Bone in a Child Seven Months Old 8 

12. Cartilage of the Concha Auriculi and External Auditory Meatus.. 10 

13. Direct Communication between the Cartilage of the Auditory Canal and 

the Tympanum 11 

14. Horizontal Section through the Left Ear of a Fourteen- year-old Boy. . 12 

15. Median Sagittal Section through the Head of the New-born 14 

16. Cross Section through the Eustachian Tube 15 

17. Right Malleus, Lateral Aspect 18 

18. Right Malleus, Internal Aspect 18 

19. Right Incus, Interior Aspect 18 

20. Right Malleus and Incus in Natural Position, Interior Aspect 19 

21. Right Stapes 19 

22. Right Tympanic Membrane and Auditory Ossicle of a Two-months-old 

Infant 20 

23. Horizontal Section through the Tympanic Membrane of a New-born 

Child 21 

24. Picture of Normal Tympanic Membrane 22 

25. Cross Section through the Tympanic Membrane of a New-born at the 

Level of the Manubrium 22 

26. Radial and Circular Fibres of the Tympanic Membrane 23 

27. Horizontal Section through the Tympanic Membrane of the New-born 

at the Level of Shrapnell's Membrane 24 

28. Horizontal Section through the Tympanic Cavity of a New-born at the 

Level of the Short Process and the Chorda Tympani 25 

29. Dendritic Network of the Medial Surface of the Tympanic Membrane. . 26 

30. Right Lateral Wall of the Tympanic Cavity, Interior Aspect 27 

31. Left Lateral Wall of the Tympanic Cavity, Interior Aspect 27 

32. Right Lateral Wall of Tympanic Cavity, Interior Aspect 27 

33. Flat Section through Antrum Tympanicum and the Mastoid Process. . 2S 

34. Lateral Surface of Temporal Bone of Twelve-year-old Child 29 

xi 



xii LIST OF ILLUSTRATIONS 

35. Temporal Bone of Fourteen-year-old Boy with Congenital Stenosis of 

the Exterior Meatus 30 

36. Temporal Bone with Persistent Squamo-mastoid Fissure 31 

37. Vertical Section through a Pneumatic Mastoid 31 

38. Vertical Section through a Diploic Mastoid 31 

39. Normal Pneumatic Tissue of the Mastoid 32 

40. Normal Temporal Bone with Conical Mastoid Process; Oval Cross Section 

(Twelve- year-old Child) 33 

41. Bullously Enlarged (Distended) Normal Mastoid Process 33 

42. Vertical Section through the Labyrinth. Topography of the Ampullae 35 

43. Frontal Vertical Section through the Vestibulum 30 

44. Axis Section through the Cochlea of a Twelve-year-old Child 37 

45. Axis Section through the Basilar Convolution of the Cochlea 40 

46. Cavity of the Bony Labyrinth 43 

47. Topographical Division of the Tympanic Membrane 57 

48. Graphic Representation of Rinne's Test for Clinicodiagnostio Purposes 73 

49. Rotating Chair 91 

50. Table for- Dotting in the Findings of the Functional Tests 96 

51. Graphic Representation of the Quantitative Tuning-fork Tests Based 

on Bezold's "Acoustic Relief." 96 

52. Coloboma of the Concha with Asymmetry of the Skull and Micrognathia 

(Smallness of the Jaws) in a Twelve-year-old Girl 99 

52a. Anterior Aspect of Case Shown in Fig. 52 100 

53. Macrotia with Disfiguring Enlargement of the Lobe. Boy Fourteen 

Years Old. Cured by Plastic Operation 100 

54. Macrotia with Accessory Tragus. Boy Three Weeks Old 101 

55. Macrotia with Multiple Pre-auricular Appendages. Left Side of Fig. 

58. Boy One Year Old 101 

56. Macrotia with Micrognathia and Multiple Pre-auricular Fistul.e in 

Boy Three Months Old 101 

57. Congenital Atresia of the Left Auditory Duct, with Rudimentary De- 

velopment of the Concha 102 

58. Congenital Atresia of the External Auditory Duct, with Microtia. . . . 103 

59. Congenital Atresia of the External Auditory Duct, with Defective 

Development of the Helix Ascendens and a Pre-auricular Appendage 104 

60. Shrinking of the Concha after Suppurative Perichondritis 107 

61. Conical Exostosis of the External Auditory Duct Following Fracture 

of the Duct 109 

62. Pressure Necrosis of the Auricular Cartilage in a Child Three Years 

Old 112 

63. Pointed Hook for Removal of Foreign Bodies 119 

64a 1 (Edema of the Mastoid Region with Painful Swelling, in Furunculosis 
646 / of the Right External Auditory Duct 126 

65. Traumatic Rupture of the Tympanic Membrane after a Blow on the Ear 130 

66. Considerable Retraction with Pronounced Protrusion of the Posterior, 

Superior, and Anterior Folds of the Tympanic Membrane 136 

67. Tympanic Membranes in Catarrhal Affections of the Middle Ear 140 

68. Lateral Wall of Right Tympanic Cavity and Membrane in a Chronic 

Adhesive Process 143 



LIST OF ILLUSTRATIONS xiii 

69. Formation of Vesicles and Sacs (Prolapse) in Serous and Purulent In- 
flammation of the Middle Ear 148 

70 Acute Purulent Inflammation of the Middle Ear during Influenza. . 153 

71. Intermediary (free) Lime Deposits in the Tympanic Membrane 158 

72. Acute Mastoiditis with Suppuration in a Mastoid Air-space. Boy Twelve 

Years Old 166 

73. Acute Mastoiditis. Boy Six Years Old 166 

74. Typical Cleft of the External Auditory Duct and Descending Postero- 

superior Wall of the Duct in Acute Purulent Mastoiditis 167 

75. Descending Posterosuperior Wall of the Auditory Duct and Cleft-like 

Construction of the Duct in Acute Suppuration of the Antrum and 
Pars Mastoidea in a Child Three Months Old 167 

76 \ Purulent Mastoiditis with Multiple Fistula Formation and Fistulous 

77 J Perforation into the Sulcus Sigmoideus 168 . 

78 \ Pathognomonic Position of the Concha in Acute Purulent Mastoiditis. 

79 J Boy Fourteen Years Old 171 

80. The Mastoid Triangle 177 

81. Right Ear '. 177 

82. Tympanic Membranes in Chronic Middle-ear Suppuration 181 

83. Tympanic Membrane of the Right Ear in Chronic Middle-ear Suppura- 

tion after Acute Infections 182 

84. Sequestration of the Tegmen Tympani of the Left Temporal Bone in a 

Girl Four Years Old 191 

85. Cholesteatoma of the Middle Ear and Labyrinth 196 

86. Frontal Longitudinal Section through the Right Temporal Bone 197 

87. Frontal Longitudinal Section through the Right Temporal Bone 198 

88. Cholesteatoma Cavity of the Mastoid Process 198 

89. Tympanic Membrane in Chronic Epitympanic Middle-ear Suppuration. . 201 

90. Chronic Attic Suppuration with Destruction of the Lateral Attic Wall 201 

91. Topography of the Middle Ear 203 

92. View of the Operative Field after Complete Conservative Exposure 

of the Middle-ear Spaces 205 

93. Suppurative Paralabyrinthitis of the Lateral Wall of the Labyrinth 258 

94. Suppurative Ostitis of the Capsule of the Labyrinth 259 

95. Caries of the Petrous Bone 260 

96. Pathognomonic Change of Position of the Right Concha in Right-sided 

Subperiosteal Mastoid Abscess 279 

97. Otoscopic Findings in Fistula of the Antrum or Auditory Canal 2S4 

98. Normal Mastoid Process 2S7 

98cr. Mastoid Cells with Diploic Apex 287 

99. Anatomy of Bezold's Mastoiditis 288 

100. Left Otitic Descending Abscess 289 

101. Schematic Frontal Section through the Right Mastoid Process 290 

102. Otitic Descending Abscess, the Pus Descending Toward the Nape. Four- 

Year-old-Girl 291 

103. Bezold's Mastoiditis 292 

104. Cross Section through the Sinus Sigmoideus in Infectious Thrombo- 

phlebitis 303 

105. Obturating, Infectious, Fusiform Thrombus with Pointed Ends 304 



xiv LIST OF ILLUSTRATIONS 

106. Infectious Thrombus Removed by Operation from the Sinus Sigmoideus 

OF A NlNE-YEAR-0LD-B0Y 394 

107. Thrombus Removed by Operation from the Sinus Sigmoideus, Sinus Trans- 

versus, and the Bulbus Jugularis 304 

108. Thrombus Removed by Operation from the Sinus Transversus in Extensive 

Infectious Thrombophlebitis 305 

109. Infectious Thrombus Removed by Operation from the Vena Jugularis 

Interna 305 

110. Vena Jugularis Interna, Filled with Thrombus Masses and pus, Extir- 

pated Together with the Bulbus 306 

111. Schematic Representation of Exposure of Sinus and Dura 311 

112. Cerebral Base of a Boy, Fourteen Years Old 329 

113. Abscess of Temporosphenoidal Lobe 338 

114. The Infectious Tracts Leading from the Ear into the Posterior Cranial 

Fossa 348 

115. Girl, Thirteen Years Old. Abscess of the Right Cerebellar Hemisphere 349 

116. Horizontal Section through the Cerebellum and the Crus Cerebri. . . . 350 

117. Minute, Cobweb-like Coagulations of Spinal Fluid in Tuberculous Menin- 

gitis in a One-year-old Child 3.57 

118. Typical Columnar Coagulation with Adhesive Threads at the Top and 

Bottom of the Test-tube 357 

119. Conical Coagulation Ending in a Point, in Suppurative Meningitis.... 357 

120. Sarcoma of the External Ear and Middle Ear 363 

121. Tuberculosis of the Lobule of the Ear in a Child Five Years Old. . . . 390 

122. Pre-auricular and Auricular Skin Tuberculosis in a Six-months-old Child 391 

123. Tuberculosis of the Temporal Bone in a Child of Five Years 392 

124. Extensive Caries of the Temporal Bone with Complete Destruction of 

the Middle Ear and Formation of Multiple Fistula 393 

125. Tuberculous Caries of the Right Temporal Bone of a Child, Four Years 

Old 394 

126. Tuberculous Mastoiditis with Complete Disintegration of the Corti- 

calis and the Posterior Wall of the Auditory Meatus 394 

127. Chronic, Tuberculous Suppuration of the Middle Ear 395 



LIST OF ILLUSTRATIONS xv 



LIST OF PLATES 

I. Normal Auricle of Ear in Two-year-old Boy. Normal Auricle of Two- 
year-old Boy Enlarged to Size of Four-year-old Child. Normal 

Auricle of Four-year-old Boy. Normal Auricle of Adult 10 

II. Frontal Vertical Section through Ear of New-born. Infant, Twelve 

Weeks Old 22 

III. Diagram of Membranous Labyrinth. Topography of Osseous Capsule of 

Labyrinth and Membranous Labyrinth. Ramification of Nerves of 
Membranous Labyrinth and its Nerve-endings 32 

IV. Osseous Labyrinth of Two-months-old Child. Horizontal Section 

through Temporal Bone of Twelve- year-old Child. Lateral Wall 

of Labyrinth 38 

V. Frontal Section through Nucleus of Labyrinth. Topography of Osseous 
Semicircular Canals. Window of Labyrinth with Vestibule. Medial 

and Posterior Walls of Vestibule 40 : 

VI. Attic Vestibule, Antrum, and Cochlea. Temporal Bone of Two-year-old 
Child. Topography of Labyrinth, Posterior and External Aspects. 
Labyrinthine Nucleus of Petrous Bone of Three-year-old Child. 

Modiolus 46 

VII. Topography of Ear, Facial Nerve, Cochlea, and Vestibule of Antrum.. 48 

VIII. Pathological Otoscopic Findings of Tympanic Membrane 140 

IX. Topography of Otogenic Abscess of Tympano-sphenoidal Lobe 346 



The Diseases of Children 



I. ANATOMY OF THE EAR 



Fig. 1. 



Pm 



I. THE TEMPORAL BONE 

The bony foundation of the ear is formed by the temporal bone. 
In the newly born (Fig. 1) this consists of three sections, which in the 
course of further development grow together. They are the petrous, 
the squamous, and the tympanic portions. Posteriorly, the petrous 
portion ends in a broad base (mastoid part). 

The squamous part of the temporal bone has two surfaces, an ex- 
ternal and an internal. The upper edge of the squamous portion is 
connected with the parietal bone through the squamous suture, which 
admits only of slight dilatation of the 
skull. Anteriorly, the squamous bone 
sends forward the zygomatic process, 
which represents the border between the 
upper vertical and the lower horizontal 
portions of the squamous part of the 
temporal bone. The latter ends in two 
divergent cortical plates (Fig. 2); the 
upper one turns toward the anterior sur- 
face of the petrous bone and forms by 
junction with the similar petrous process 
the roof of the tympanum (paries teg- 
minis, tegmen tympani) (Fig. 2) and the 
petrosquamous fissure. The lower corti- 
cal plate ends with a free edge, forming 
the lateral attic wall (Fig. 2, la). At the 
medial plane of the squamous portion 
there are the impressiones digitatse, and 

a branching fossa destined to receive the middle meningeal artery. The 
anterior edge of the squamous portion forms with the petrous bone an 
interior angle in which the canal for the Eustachian tube and the tenso- 
tympani muscle terminates. Anteriorly to the auditory canal at the 
lower surface of the squamous portion there is the mandibular fossa, 
which is intended for the capitulum of the inferior maxilla. At the con- 
cave part of the tympanic ring (annulus tympanicus) there is the groove 
which will serve for the insertion of the tympanic membrane. The trans- 
formation of this ring into the tympanic bone is described on page 6. 

Vol. VI.— 1. 1 




Temporal bone of the new-born, consist- 
ing of the squamous (squama temporalis, 
Squ), the mastoid (Pm), the petrous (Pp) 
and the temporal portions (annulus tym- 
panicus, At), the latter of which becomes the 
tympanic portion. Pz, zygomatic process; 
Fv, fenestra vestibuli; Fc, fenestra cochlea?; 
P, promontory; Fsm, stylomastoid foramen. 



THE DISEASES OF CHILDREN 



If the squamous portion and tympanic ring are removed from the 
pyramid of the petrous bone in the new-born or in a preparation of the 
adult, a quadrangular pyramid will be seen, the base of which lies in the 
mastoid process, while the apex points forward and inward in the natural 
position of the skull. Two of the four surfaces are intracranial and two 
extracranial at the outer surface of the skull. The anterosuperior intra- 
cranial surface is called the cerebral surface, and the posteroinferior 
one the cerebellar surface. The upper edge of the petrous bone, which is 
bounded by the two surfaces, is also the border between the middle and 
posterior cranial fossae. Posteriorly, the upper edge of the petrous bone 



Fig. 2. 



Csl 




Sgu 



Pm 

Vertical frontal section through the temporal cavity. Topographic arrangement of the tympanic 
cavity. M, mesotympanum; E, epitympanum; H, hypotympanum; Pm, mastoid process; Fj, jugular fossa; 
Tb, fundus of the tympanic cavity; V, vestibule of the labyrinth; Csl, protrusion of the horizontal semicircular 
canal; Squ, squamous portion of the temporal; og, superior auditory canal; la, lateral attic wall; hg, posterior 
auditory canal; Tt, tegmen tympani (paries tegminis). 

runs into the upper edge of the transverse groove of the occipital bone. 
The cerebral surface of the petrous bone terminates exteriorly at the 
tegmen tympani and, in infants, is separated by the petrosquamous 
fissure from the corresponding squamous process, the upper osseous 
semicircular canal protruding ridge-like behind the middle of the plane. 
It forms the roof of the fossa subarcuata, a cavity the size of a small pea 
which becomes partly or completely obliterated at a later period. While 
this takes place, there will be osseous growth at the entrance to the fossa 
(Fig. 11), but the soft contents may remain intact for a long time, and 
remnants of it may even be preserved in adults. In some animals, 
especially the rodents, the fossa subarcuata is very roomy in spite of its 
relatively small entrance, and is filled with flocculus cerebelli. 



ANATOMY OF THE EAR 3 

In the new-born and infants during the first year of life, there is 
the superficial hiatus spurius at the lateral margin of the upper surface, 
which is a lateral aperture of the facial canal, the latter running at this 
place downward and backward. Later it is covered by a small plate of 
bone which is shifted over it from behind. The canal for the Vidian 
nerve extends from the hiatus to the apex of the petrous bone. At the 
apex itself there is the depression which is destined to receive the tri- 
geminal ganglion. 

The cerebellar surface of the petrous bone (Fig. 5) is bounded later- 
ally and posteriorly by the sigmoid sulcus. At about the middle, the 
internal auditory meatus (meatus acusticus internus) is situated, with 
its longitudinal axis running a purely frontal course from right to left. 
Its length in the new-born does not exceed 4-6 mm., its full length of 
10-12 mm. not being attained until puberty. 

The fundus of the internal auditory canal is divided by a trans- 
verse crest into a small, superior, and a large, inferior, section. The 
nerves are inserted into their respective osseous canals within the fundus. 
The entrances are formed either by isolated gaps or cribriform aper- 
tures. One of the isolated gaps is intended for the facial nerve and 
another for the inferior ampullar nerve. 

The osseous crest mentioned above and the area cribrosa which 
lies immediately underneath are intended for the accommodation of 
the nerves to the utricle and ampulla. The antero-inferior part of the 
fundus contains the tractus spiralis foraminosus, through which the 
cochlear nerve, coming from the cochlea, enters the internal meatus. 

The arrangement of the cribriform gap of the tractus spiralis for- 
aminosus indicates the spiral convolution of the cochlea. The area 
cribrosa media consists of a number of small gaps and is situated between 
the tractus and the superior macula cribrosa, receiving the nerve branches 
intended for the vestibular portion of the cochlear duct and saccule 
(Plate III, Fig. 3). 

At about the middle, between the internal auditory meatus and 
the sigmoid sulcus, lies the external aperture of the vestibular aqueduct. 
In the first year of life it occupies a superficial position (Fig. 3) ; later on 
a small osseous plate grows over the aperture (apertura externa aquse- 
ductus vestibuli), similar to the osseous plate of the hiatus spurius facial 
canal, so that the aperture of the vestibular aqueduct assumes the shape 
of a longitudinal fissure and has the appearance of being laterally dis- 
placed (Fig. 4). 

From above, the fossa subarcuata extends as far as the cerebellar 
surface of the petrous bone. After obliteration of this fossa there is 
sometimes a cicatricial cavity near the upper edge of the petrous bone, 
which may be mistaken for the external aperture of the aquseductus 



THE DISEASES OF CHILDREN 



vestibuli. Below the aperture of the internal auditory canal, at the 
border angle of the cerebellar and inferior surface of the petrous bone, 
there is the triangular aperture of the cochlear aqueduct (Figs. 4-6). 



Fig. 3. 
Cvii Acs Ea Fsu 




Aqu 



Tsp 



Petroua portion of the tsmpanum in a six- 
months-old infant. Posterior surface of the petrous 
bone with the internal auditory meatus and the 
fossa subareuata (Fsu). In the fundus of ihe in- 
ternal auditory meatus is the aperture of the canal 
of the facial (Fallopii) (Cvii), area cribrosa sup- 
erior (4cs), area cribrosa media (Acm), the foramen 
singulare (Fs), and the tractus spiralis foramino- 
sus (Tsp). Ea, eminentia arcuata; Aqu, external 
aperture of the aquceductus vestibuli. 



Fig. 4. 




Posterior surface of the petrous bone in a ourteen- 
year-old child. Strongly developed angle (a) of the 
sigmoid sulcus (Ss). Fo, jugular foramen; Pat, inter- 
nal auditory meatus; Aqu, aquseductus vestibuli; Ac, 
aquseductus cochlea?. 



Fir, ft 



Fig 6. 




Surgically important parts of the inferior surface of the temporal bone. Cc, carotid canal; Ac, aquseduetus 
cochleae; a, insertion field for the muscles of the tube and palate. Fig. 5. Deep and large jugular fossa (Fj); 
normal incisura mastoidea (Im). Fig. 6. Flat and small jugular fossa (Fj), apex of mastoid process (Pm). 
Incisura mastoidea only indicated (Im) ; it is so flat that the mastoid cells closely approach the stylomastoid 
foramen (Fsm). 



The medial part of the inferior surface of the petrous bone is oc- 
cupied by the jugular fossa (Figs. 5 and 6). In front is the carotid canal, 
which traverses in semicircular form the anterior part of the petrous 
bone. There is also a rough area, the field of insertion for the Eusta- 



ANATOMY OF THE EAR 



Fig. 7. 



E VII Fv 



A Css 



chian tube and the soft palate. Behind the carotid canal is the flat 
fossula petrosa, from which a number of small canals lead to the middle 
ear. 

Postero-exteriorly from the jugular fossa is the external aperture of 
the facial canal, the stylomastoid foramen; and from the end of the first 
year of life the styloid process can be found immediately in front of the 
facial canal and at the same depth. 

The lateral surface of the petrous bone is only visible in the new- 
born and up to the end of the first year (Fig. 1) ; later on, it can only be 
seen after resection of the squamous part of the temporal bone and the 
tympanic bone. The central part of the surface is occupied by the ves- 
tibular window (fenestra vestibuli, Fig. 7), which is surrounded by the 
facial canal running in a postero-inferior direction toward the antrum. 
In the young, the facial 
canal is often detached 
close to the vestibular 
window, and the nerve at 
that place is only covered 
by connective tissue. 
This condition often ex- 
ists to the fourth year, 
and explains the fact that 
in acute otitis media 
there is more frequently 
peripheral paralysis of 
the facial nerve in chil- Cm 

dpf>n thfln in fldlllts Medial wall of the tympanic cavity of the new-born. B, epitym- 

panum; VII, facial canal; Fv, fenestra vestibuli; A, antrum; Css, 
The lateral SUrfaCe superior semicircular canal; Bp, eminentia pyramidalis; Fc, fenestra 

cochlea?; P, promontory; Cm, semicanalis muscle. 

of the petrous bone has 

a groove-like cavity corresponding to the antrum; in the medial part of 
this cavity protrudes the external osseous semicircular canal in the shape 
of an oblong ridge. Behind the inferior pole of the vestibular window 
is the hollow pyramidal process, which is intended to receive the stapedius 
muscle. Before and below the vestibular window are the promontory and 
the fenestra cochleae; above the promontory, runs more or less vertically 
the canal for Jacobson's nerve (Jacobsonii) . 

The tympanic groove extends upward to the hiatus spurius of the 
facial canal, while inferiorly it fuses with a short canal which terminates 
at the inferior surface of the petrous bone in the fossula petrosa. At 
the anterior pole of the vestibular window the processus cochleariformis 
is visible in the shape of a freely protruding osseous blade. This is the 
posterior end of the bony crest through which the canal for the Eusta- 
chian tube and tensor tympani muscle is divided into an upper and a 




6 THE DISEASES OF CHILDREN 

lower section. The crest running along the lateral surface of the petrous 
bone as a rule does not go beyond the middle of the lumen of the canal, 
but sometimes it extends further, and occasionally the osseous septum 
completely separates the canal into the two sections mentioned. The 
upper section is intended for the muscles of the tensor tympani, the 
lower one for the Eustachian tube (semicanalis tensoris tympani and 
seminalis tubas). 

II. CHANGES OF THE TEMPORAL BONE DURING GROWTH. 

The temporal bone of the new-born consists of diploic bones, with 
the exception of the bony capsule of the labyrinth, the latter having at 
least a thin layer of compact bone. The upper ends of the tympanic 
ring blend with the squamous part in the first few months, the medial sur- 
face of the squamous portion growing almost simultaneously with the 
circumscribed places of the petrous bone (Fig. 10). The transformation 
of the tympanic ring into the tympanic bone is complete at the end of 
the fourth year, provided there is normal general development of the 
skeleton, but under certain circumstances the gap may persist longer 
and in rare cases even permanently (Fig. 9). Development of the mas- 
F toid process to any noteworthy size does 

Mai not occur before the end of the first year. 

Obliteration of the fissura squamomas- 
toidea commences at the end of the first 
year and is usually completed at the end 
of the second. Some sections of the petro- 
squamous fissure persist until the fourth 
year, sometimes permanently. The tym- 
panosquamous fissure will permanently 
persist. 
Posterior surface of the petrous bone. The intramastoid fissure is seldom 

Jugular fossa enormously enlarged and 

extending to the vestibule and into the me t with and, if present, obliterated at 

internal auditory canal (.Mai). m 

the end of the second year; its remnants, 
however, are sometimes demonstrable permanently in the shape of 
fossicular cavities. 

The lateral surface of the petrous pyramid shows the smallest 
changes in the course of growth, showing merely a sharper outline and 
an increase in size corresponding to the growth of the entire pyramid. 
On the other hand, the jugular fossa at the inferior surface of the petrous 
bone grows considerably deeper, and the styloid process ossifies at the 
end of the first year. This may take place from the base (Politzer) or 
from the apex. Before both ossifications have reached each other, the 
ossified apex has become connected with the temporal bone by syn- 
chondrosis (Henle). 




ANATOMY OF THE EAR 7 

The following changes during growth of the cranial surfaces of the 
petrous pyramid should also be mentioned : 

(1) Occlusion and obliteration of the fossa subarcuata; 

(2) Covering of the superficial upper semicircular canal in the 
circular commissure and of the upper half of the sagittal semicircular 
canal by a compact osseous layer 2-5 mm. thick; 

(3) Superposition of a compact layer, 3-7 mm. thick, over the upper 
pole of the cochlea; 

(4) Growth of a protruding osseous layer over the hiatus spurius 
of the facial canal; 

Fig. 9. 




Mae Pin O 

Persisting gap in ossification of the tympanum (0). Mae, external auditory meatus; Pm, mastoid process. 

(5) Growth of a protruding osseous layer over the exterior aperture 
of the vestibular aqueduct ; 

(6) Prolongation of the cochlear aqueduct; 

(7) Considerable elongation of the internal auditory canal with 
moderate narrowing of its superficial entrance; 

(8) Deepening of the sigmoid sulcus; growth of the sulcus petrosus 
superior and inferior as well as of the sulcus petrosquamosus, provided 
a petrosquamous sinus has persisted. 

Between the fifth and fifteenth years a gradual deepening of the 
groove for the middle meningeal artery and of the impressiones digitatae 
of the squamous part of the petrous bone occurs and may still further 



8 



THE DISEASES OF CHILDREN 



increase in the course of later years. In exceptional cases the protru- 
sion of bones may develop into commissures closing the sulcus petrosus 
or the sulcus arterial meningeal at circumscribed places in the shape of 
canals. 



Fig. 10. 




Pm 



Fig. 11. 



O Fv 

Lateral surface of temporal bone in a one-year-old child. Sgu, squamous portion of temporal; Im, incisura 
mastoidea; Fv, fenestra vestibuli; Ip, incisura parietal is; Fc, fenestra cochleae; O, gap of ossification; Pm, 
mastoid process; P, promontory; Pz, zygomatic process. 

If the jugular fossa is very deep (Figs. 5 and 6), the fundus of the 
tympanic cavity becomes as thin as paper and may undergo cribriform 
perforation or complete detachment. In rare cases the jugular fossa 
may even extend to the internal auditory canal, so that the internal 

auditory canal will communicate with the 
jugular fossa by an aperture (Fig. 8). 

There are three types to be differen- 
tiated in the topographical conditions from 
the sigmoid sinus to the mastoid process: 
(1) The sinus, in normal position, 
runs in the projection of the posterior half 
of the mastoid process, while the anterior 
border of the sinus does not protrude 
beyond a straight line connecting the 
tuberculum supramastoideum with the 
apex of the mastoid process anteriorly. 

(2) The second typical position is due to the sinus growing more 
remote from the mastoid process, the flat sigmoid fossa being shifted pos- 
teriorly and upward. 

(3) The third typical position is caused by anteposition of the sinus 
and ectasis of the sigmoid sinus. In this case the anterior border of the 
sinus protrudes beyond the medial borderline anteriorly. In cases of 
extensive ectasis the tissue of the mastoid process is pushed to the area 




Pai a 



Right petrous bone in a child seven 
months old. The fossa subarticulata is 
in the course of being obliterated by a 
growing protruding bone, b, superior 
edge of the petrous bone; Pai, internal 
auditory meatus. 



ANATOMY OF THE EAR 9 

of the apex, while the antrum region is occupied by the extended sinus. 
The latter is bluish-black in color and can be seen through the extremely 
thin lateral wall of the mastoid process. 

m. THE EXTERNAL EAR. 

The external ear consists of the concha and the external auditory 
meatus. The concha is formed of duplicature of skin which is kept in 
normal shape and position by the auricular cartilage. The concha in 
the child is remarkably soft and but slightly elastic in the first few weeks. 
At this stage its shape is rather shallow, while its retroverted margin 
(helix) is sometimes disproportionately large. 

The growth of the concha during the first two years is remarkably 
rapid, the cartilage stiffens and its lateral surface deepens. During the 
same period the central parts (cymba conchse, fossa navicularis, anti- 
helix) develop much more markedly than the marginal parts (Plate I, 
Fig. 1), as can be very plainly observed by comparing the length of the 
conchse of two children, aged two and four, respectively (Plate I, Fig. 2). 
Pronounced growth of the free fold does not set in until the third or 
fourth year (Plate I, Fig. 3), while the lobe will usually not show any 
marked increase until puberty (Plate I, Fig. 4) . 

The external auditory meatus consists of a lateral and a medial 
section. The fundus of the lateral half is formed by connective tissue 
and cartilage (membrano-cartilaginous part), while that of the medial 
half is formed by bones (osseous part). The integument of the lateral 
part of the external meatus contains the normal papillae, hairs, sebaceous 
glands and the ceruminal glands, the latter secreting a light yellow, 
clear, oily fluid. If this secretion is mixed with desquamated epithelial 
cells, dust, etc., a waxlike mass of yellowish-brown to black coloration 
will be formed in the outer meatus without any particular pathological 
cause (cerumen, ceruminal core). 

The cartilaginous part can be stretched and distended. By trac- 
tion it can be elongated by 4-5 mm., and by insertion of a small distend- 
ing tube it may be widened by 3-2 mm. The integument of the osseous 
canal has neither hairs nor glands; it is attenuated toward the inner end 
of the canal, and the papillae at that place become small and shallow. 
The subcutaneous cell tissue is but little developed at the end of the 
osseous canal in the vicinity of the tympanum. 

The longitudinal axes of the cartilaginous and osseous canals join 
in an obtuse angle of 120-150°, which is open anteriorly and inferiorly. 
If the angle is very obtuse, the curvature of the entire external canal 
will, of course, be only slight and semicircular, while the angular kink- 
ing of the fundus of the external meatus at the transition of the mem- 
branous into the osseous part will be the more pronounced, the acuter 



10 



THE DISEASES OF CHILDREN 



Fig. 12. 



Fvii 



the angle. In the latter case, the "cellar" of the external canal is very 
deep, so that the antero-inferior quadrant of the tympanum is incom- 
plete or quite invisible in the otoscopic picture. 

There are three parts to be distinguished in the cartilage of the 
auditory canal: the tragus layer, the median commissure and the basal 
layer (Munch, Schwalbe). 

By pulling the concha backward and upward, the auditory canal 
may be completely straightened out, especially in infants. 

The movable and elastic properties of the membranous auditory 
canal are based upon the fact that the base of the cartilaginous canal is 

not formed by a cartilagin- 
ous tube, but a cartilaginous 
groove which is open back- 
ward and upward, while at 
its anterior and inferior 
walls it is provided with 
fissures. (Santorini's fis- 
sures.) Furthermore, the 
ear cartilage is not always 
directly inserted, but con- 
nective tissue may be inter- 
polated at the lateral end 
of the osseous canal (Figs. 
12 and 13). 

The greater part of the 
cross section of the external 
auditory canal is perfectly 
round. At the distal end of 
the membranous part, the 
cross section has sometimes 
a pronounced oval form 
with a vertical longitudi- 
nal axis, while the middle part of the osseous canal has in many cases 
the shape of a transverse oval. In other cases the border region at the 
posterior wall between the cartilaginous and osseous canals protrudes 
in a hump-like curvature, imparting to the cross section a bean- or 
kidney-like shape with a backward direction of the helix. 

The anterior half of the concha is provided with sensitive fibres 
of the trigeminal, the posterior half with fibres of the great auricular 
nerve, coming from the superior cervical plexus, while the sensitive 
nerves of the exterior auditory meatus are supplied by the auricular 
branch of the vagus (Arnold's nerve). The latter enters the concha 
from below and behind, sending ramifications through the concha and 




Cartilage of the concha auriculi and externa! auditory meatus. 
Left ear, inferior aspect. Fissure (a) and gap formation (6) in 
the cartilage of the canal, which is inserted at the tympanum by 
a broad ligament of connective tissue. Fts, tympanosquamous 
fissure; Fvii, stylomastoid foramen; Ch, cauda helicis; Pm, mas- 
toid process; Im, digastric fossa. 



PLATE I. 




Fig. 1. Normal auricle of the ear in a two- 
year-old boy. The central portions of the auri- 
cle, especially the conchial cavity, are relatively 
large. The lobule (a) is small. 



Helix 



Fossa navlcularis 

Helix ascendens 

Crus anthelicis 

Anthelix 



Cymba concha / 
Cavitas concha 

Meatus acusticus externus 




Antitras.us 



obulus auricula 



Fig. 2. Normal auricle of a two-year-old 
boy enlarged to the size of a four-year-old 
child. The disproportionate enlargement of 
the conchial cavity and the navicular fossa is 
seen by comparison with Fig. 3. 



Top point 
Helix horizontalis 




Darwin's point 

Fossa navicularis 

Helix descendens 

Anthelix 



Cavitas concha 



Fig. 3. Normal auricle of a four-year-old 
boy. 



Meatus acusticus externus 



Crus anthelicis sttperius 



Helix ascendens 



Crus anthelicis 
inferius 

Cymba conchce 

Crus lielicis 



Tragus 




Lobulus auricula? 
Fig. 4. Normal auricle of an adult. 



ANATOMY OF THE EAR 



11 



into the posterior and inferior walls of the external canal. The motor 
nerves of the concha are supplied by the facial nerve. 

The arteries of the external ear come from the area of the external 
carotid. The most important of these is the deep auricular artery which 
supplies the external auditory canal and leaves, together with the tym- 
panic artery, the maxillary internal at the place where the latter crosses 
the neck of the capitulum of the submaxillary bone. 

The postero-superior osseous wall of the auditory canal is formed 
by the anterior wall of the maxillary process and the lateral attic wall, 
while the exterior part is formed by the horizontal portion of the squa- 



Fig. 13. 




Direct communication between the cartilage of the auditory canal (a) 
and the tympanum. Fm, mandibular fossa; Pst, styloid process. 

mous portion of the temporal bone. The antero-inferior wall of the 
osseous external auditory canal is formed by the os tympanum. 

The development of the concha commences in the second embryo- 
nal month and starts from the sixth auricular eminence. These auricular 
tuberosities are grouped around the external auditory meatus. The 
external canal itself is developed rather late in the shape of a blind 
digitated process, commencing at the meatus. According to Urban- 
tschitch, the occlusion of the external canal, both in the embryo and 
the new-born, is caused by embryonal agglutination, and the canal is 
seen to be completely filled with epidermal cells, both in the embryo and 
the new-born, sometimes even several weeks after birth. 

The resorption of these cells commences after birth. The thick 



12 



THE DISEASES OF CHILDREN 



Fig. U. 



Pao 



epidermal layer becomes desquamated and is removed along with the 
secretion of the glands of the external canal. It is only rarely that the 
canal seems free from epidermal cells before birth, but even after com- 
plete desquamation of the embryonal tissue the auditory canal of the 
infant is not freely permeable, nor is it filled with air. Softness of the 
cartilage and absence of any osseous support cause the upper and lower 
walls to lie flat upon each other, so that the canal has the appearance of 
terminating in a fissure from an antero-superior to a postero-inferior 
direction. The osseous external canal is entirely absent in the new- 
born, as its surrounding 
osseous parts are not yet 
formed. The infant has no 
mastoid process, while the 
tympanic bone exists in the 
shape of a narrow, osseous 
groove in the shape of about 
three-quarters of a circle 
(Fig. 1), which is intended 
for the insertion of the tym- 
panum and the membrano- 
cartilaginous canal. The 
membranous canal is con- 
nected with the almost hori- 
zontal lateral attic wall by 
thick connective tissue for- 
mation (Plate II). The 
permeability of the external 



Pac 




Pm 



Horizontal section through the left, ear of a fourteen-year-old 
boy. Aspect of the superior half of the section. Cy, cymba con- 
cha;; H, helix; Pac, anterior wall of the membrano-cartilaginous 
auditory canal; Pao, anterior wall of the osseous auditory canal; 
Pm, mastoid process; Mi, tympanic membrane; Sta, stapes with 
stapedius muscle; Mtt, tensor tympani muscle; Co, cochlea. 



canal becomes established 
at a later period when the 
cartilage becomes harder 
and more elastic . This rudi- 
mentary lumen is widened 
when the annulus tympanicus is transformed into the tympanic 
bone simultaneously with the glenoid fossa for the insertion of 
the capitulum of the submaxillary bone. The membrane which in the 
new-born occupies the place of the tympanic bone becomes gradually 
ossified. 

Ossification and increased growth of the newly-formed osseous 
layer take place from the margin, and this accounts for the fact that at 
the end of the second year there is a gap in the centre of the tympanic 
bone opposite the tympanum, which is occluded by connective tissue 
(Fig. 10). This gap disappears in many cases in the third year, but 
may persist longer, in exceptional cases even permanently (Fig. 9). 



ANATOMY OF THE EAR 13 

Formation of the posterior wall of the osseous external canal de- 
pends upon the development of the mastoid process, which is only present 
to any noteworthy extent after the infant is able to keep up and balance 
his head by the function of the cervical muscles. This, however, will 
not be the case before the end of the first year. In rachitis and arrested 
development the mastoid process is often rudimentary as late as the 
third and fourth years. 

IV. THE MIDDLE EAR. 

The middle ear is composed of the Eustachian tube, the tympanic 
cavity, the mastoid antrum and the mastoid process. 

The tympanic cavity is divided into three spaces, according to the 
position they occupy toward the tympanum, as follows : 

(1) Mesotympanum (median cavity of the tympanum, principal 
space of the tympanic cavity) ; (2) Epitympanum (cupola, attic or upper 
space of the tympanic cavity); (3) Hypotympanum (basal space, cellar 
of the tympanic cavity). 

i. The Eustachian Tube (tuba auditoria). — The communicating 
tube between tympanic cavity and fauces consists of an osseous and 
membranocartilaginous part. The osseous part is situated in the lower 
portion of the canal or the Eustachian tube and tensor tympanic muscle 
and is bounded posteriorly and superiorly by the petrous bone. The 
tubal cartilage, which is bent in the shape of an S, is situated in the 
posterior wall of the cartilaginous tube (Fig. 16). It consists of spongy 
cartilage with occasional areolae or fissures. The upper margin of the 
cartilaginous layer is bent laterally. The anterior wall of the carti- 
laginous tube is fibrous; the posterior cartilaginous wall is connected 
with the basal surface of the petrous bone by firm connective tissue, 
while the anterior wall is only united by loose connective tissue. The 
free margin of the cartilaginous layer bulges out in the shape of a ridge 
at the pharyngeal aperture of the tube (ostium pharyngeum tuba?), and 
this tubal ridge forms the anterior boundary of Rosenmiiller's fossa. 
The latter is either present in rudimentary form in infants or entirely 
absent (Fig. 15). The tube crosses the pterygoid process in its course 
toward the pharynx. A few bundles of the musculus tensor veli palati 
are inserted at the lateral tubal wall, although some authors regard it 
as an entire muscle and designate it the dilator tubas. 

The cross section of the tube toward the pharyngeal ostium has a 
fissure in the shape of an S, and in a quiescent position the lateral wall 
lies closely against the medial one. As the cartilaginous tube approaches 
the osseous one, it becomes narrower, and its cross section is rounder; 
the narrowest part of the membranocartilaginous part (isthmus tuba?) 
is closed before its fusion with the osseous part. Having passed the 



14 



THE DISEASES OF CHILDREN 



isthmus, the lumen gradually becomes larger again as it approaches the 
ostium tympanicum. 

The osseous tube, together with the soft part immediately before 
it, is always open, while the rest of the membranocartilaginous tube is 
closed in the resting position. The longitudinal axis of the tube runs 
upward and outward, from behind, and the tube is generally perfectly 
straight. The cartilaginous tube contains many mucous glands (Fig. 
16) ; its mucous membrane is covered with stratified, ciliated epithelium, 
extending upward to the ostium tympanicum, frequently even to the 
mucous membrane of the hypotympanum. It has numerous very fine 
longitudinal folds, while fissures in the tubal cartilage may lead to com- 



Fig. 15. 




Median sagittal section through the head of the new-born. T, position of the pharyngeal opening of the tube; 

a, velum of the palate. 

plete isolation of some cartilaginous parts. The connective tissue in- 
vesting the surface of the tube, as well as the tympanic mucosa, is in 
direct communication with the connective tissue which fills the petro- 
squamous fissure in childhood. The entire tube in the new-born is 
17-22 mm. long, relatively wide, and sometimes gaping in the cartilag- 
inous part. The tubal cartilage is soft and not very elastic. It seems 
that the close approximation of the lateral and medial walls of the tube 
is only exceptionally present in the new-born and usually occurs in the 
first month. In the course of further development the pharyngeal 
opening of the tube gradually moves away from the choanae at the lower 
margin, apparently proceeding upward toward the cranial base. This 
change of position depends on the development of the facial cranium 
in regard to size. The hard palate continues to gradually increase its 



ANATOMY OF THE EAR 



15 



distance from the cranial base in the course of growth, whereas the 
tube which is affixed to the base of the skull remains topically unchanged 
in relation to the latter. 

2. The Tympanum. — The tympanum is a quadrangular, prismatic 
space which is connected antero-inferiorly with the tube and postero- 
superiorly with the mastoid process by means of the antrum. 

The longitudinal axis of the tympanum inclines considerably out- 
ward, forming an angle of 15-20° with the horizontal line in the new- 
born, and of 25-35° in the adult (inclination), while the tympanum 

Fig. 16. 






Cross section through the Eustachian tube. T, tubal lumen of the Eustachian tube; 6, tubal cartilage: a, a, 

pituitary glands. 

itself turns slightly forward and inward (declination), so that otoscopic 
clinical inspection from the exterior canal will make the postero-superior 
part of the tympanum appear much nearer to the eye than its antero- 
inferior section. 

The lower wall (fundus) of the tympanic cavity is formed by a 
bony layer which originates at the petrous bone and, in the new-born, 
extends to the tympanic ring. In older children and adults this part 
is fused with the tympanic bone. 

The lower surface of this osseous layer (Plate IV, Fig. 2) contains 
the fossa jugularis (Fig. 2), which is intended to receive the bulbus jug- 



16 THE DISEASES OF CHILDREN 

ularis. At its upper surface it is provided with narrow bony crests 
which, together with the entire osseous layer, represent the rudiments 
of the bulbus tympani. The latter is very strongly developed in some 
animals (equina?, rodents, carnivora) and can still be demonstrated in 
the monkey. The thickness of the osseous layer varies considerably, 
being sometimes as thick as 5-8 mm., while in other cases it is as thin 
as paper and even sometimes punctured by small holes. In rarer cases 
it is entirely absent, so that the fundus of the tympanic cavity merely 
consists of connective tissue, and the bulb of the jugular vein protrudes 
into the tympanic cavity. If the fundus of the latter is very thick 
(Plate, IV, Fig. 1), it consists of diploic bones or contains air cells (Fig. 2) ; 
if it is thin, it usually consists of a compact bony layer which does not 
contain very large areola?. 

The upper wall (paries tegminis) of the tympanic cavity (Plate IV, 
Fig. 3) is formed by the bony tegmen tympani which results from the 
union of a process emanating from the petrous bone with a correspond- 
ing plate of the horizontal portion of the squamous bone (Fig. 2). In 
the new-born, these bones are separated by the petrosquamous fissure, 
communicating only by connective tissue. The latter is in uninter- 
rupted connection with both the tympanic mucosa and dura. The 
tegmen tympani does not exceed 1-2 mm. in thickness in the majority 
of cases; in others it is either as thin as paper, or has gaps or cribriform 
perforations. If the tegmen tympani is thick, the diploic tissue of the 
horizontal squama usually extends into the tegmen. The tympanic 
tegmen (paries tegminis) is the boundary between the tympanic cavity 
and the median cranial fossa. Anteriorly, it fuses with the cover plate 
of the musculo-tubal canal, posteriorly with the roof of the antrum. 

The anterior wall of the tympanic cavity is formed by the osseous 
union between the anterior part of the tympanic bone and the petrous 
bone, with an aperture at the middle in the form of a canal. A narrow, 
bony crest, emanating from the petrous bone, divides the aperture and 
the attached canal into an upper and a lower section (Plate VII, Fig. 3). 

The upper part of the canal is intended for the tensor tympani, 
the lower one for the osseous tube. 

The posterior wall of the tympanic cavity consists of the anterior 
portion of the mastoid process with an aperture at the top the size of a 
small pea (aditus ad antrum), the cross section of which represents an 
equilateral triangle with the apex pointed downward (Fig. 2). Owing 
to the prominence of the lateral arch, the inner line of the triangle is 
slightly bulging ; the upper line is formed by the roof of the antrum and 
the lateral one by the lateral wall of the attic and antrum. 

The internal wall of the tympanic cavity is also called the laby- 
rinthine wall. Its relief is very characteristic, and the centre is formed 



ANATOMY OF THE EAR 17 

by the vestibular window (Fig. 7). Before and under this window lies 
the promontory, and in the posterior margin of the latter there is the 
cochlear window, which is situated at the bottom of a small recess (fos- 
sula fenestrae cochleae). There is a shallow furrow above the promontory 
(sulcus tympanicus s. Jacobsonii), at the end of which terminates the 
crista tympanica in a free outward eminence (processus cochleariformis). 
Posteriorly to the vestibular window, the facial canal bulges out (s. 
Fallopiae), and where the latter joins with the antrum, and in the antrum 
itself, there is the protrusion of the lateral semicircular canal. At the 
descending portion of the facial canal, immediately below the posterior 
margin of the vestibular window, there is the hollow pyramidal process, 
open at the apex, which is intended to receive the stapedius muscle, the 
tendon of which reaches the stapes through the aperture of the processus. 

The lateral wall of the tympanic cavity is formed by bones in both 
its upper and lower sections (lateral attic wall, lateral wall of the hypo- 
tympanum). The aperture which remains at the middle is closed by 
the tympanic membrane (Fig. 22). The lateral attic wall represents 
the free terminating margin of the upper osseous wall of the auditory 
canal and is regarded as genetically contemporaneous with the squamous ■ 
portion of the temporal bone (Fig. 2). 

The other osseous parts of the lateral wall of the tympanic cavity 
connect with the tympanic bone, which is provided with a sulcus at 
the inner margin to receive the tympanic membrane. The aperture of 
the latter is round and has a small indentation at the antero-superior 
part (incisura Rivini), which arises from the fact that the curved tym- 
panic bone is not closed at the antero-superior end. The lateral attic 
wall does not follow at this place the indicated circular line, but slightly 
recedes upward and outward. This causes the occurrence of small 
lateral osseous processes which are known as Helmholtz's processes. 

The lateral wall of the tympanic cavity is divided into three spaces 
for the requirements of the tympanic cavity: (1) The space lying in 
the projection of the tympanic membrane — the mesotympanum or 
principal space of the tympanic cavity; (2) the space immediately above, 
which is sometimes not much smaller than the mesotympanum, and is 
bounded by the lateral attic wall, and called the upper tympanic cavity, 
attic or epitympanum; it is of considerable clinical importance; (3) the 
space lying below the level of the tympanic membrane — the cellar or 
hypotympanum (Fig. 2). 

The oblique position of the tympanic cavity is responsible for the 
fact that, in the otoscopic picture, nearly the entire upper half of the 
tympanic wall up to the posterior part of the vestibular window appears 
to belong to the epitympanum. The lower half of the medial wall and 
the major portion of the base of the tympanic cavity belong topograph- 

Vol. VI— 2 



18 



THE DISEASES OF CHILDREN 



ically to the mesotympanum. The hypotympanum, therefore, appears 
as a shallow triangular groove. 

The lateral and medial walls of the tympanic cavity are connected 
by the chain of auditory ossicles (Figs. 17-21). The system of this chain 
in the human being can be directly derived from the simple conditions 
prevailing in reptiles and birds, where a bony rod runs transversely 
through the middle ear, with its external end affixed to the tympanic 
membrane and its medial part to the vestibular window. This columnar 
rod is called "columella." In mammals, as well as in the human being, 
there is a chain of three ossicles instead of one columella. The lateral 
end of the columella, which is connected with the tympanic membrane, 
corresponds to the malleus in man (Figs. 17, 18 and 20). 



Fig. 17. 




Right malleus, lateral 
aspect. (3.5 : 1.) a, ar- 
ticular surface for connec- 
tion with incus; Ca, head 
(capitulum) of malleus; Co, 
neck (collum) of malleus; 
Pb, short process (P. bre- 
vis) ; Ma, manubrium; b, 
grooved end of manubrium. 



Fig. 18. 




Right malleus, internal 
aspect. (3.5 : 1.) Ca, head 
of malleus; a, articular sur- 
face for connection with 
incus; Co, neck of malleus; 
b, place of insertion for muse, 
tensor tympani; M, manu- 
brium of malleus; PI, pro- 
cessus longus. 



Fig. 19. 




Right incus, interior 
aspect. (3.5 : 1.) I, body 
of incus; a, articular sur- 
face for connection with 
malleus; 6, place of inser- 
tion for posterior mal- 
leolar ligament; PI, proces- 
sus longus; c, process of 
stapes. 



The malleus consists of the head, neck and manubrium. Head and 
neck form with the manubrium an obtuse angle of about 140°. At the 
place of juncture between manubrium and neck there is a protruding, 
button-shaped, short process, while anteriorly a slender, nail-like long 
process runs toward the tympanosquamous fissure. In the new-born 
the long process shows a leaf-like broadening and is almost as long as 
the entire malleus. The peripheral part of the long process undergoes 
rapid involution, appearing in a six-months infant almost shorter than 
the short process, as in the adult. At the medial point of juncture be- 
tween manubrium and neck there is a punctiform, rough spot where 
the tendon of the tensor tympani muscle is inserted. At the posterior 
circumference of the head there is a saddle-shaped, articular surface for 
the incus. 



ANATOMY OF THE EAR 



19 




Plm 



Right malleus and incus in natural 
position, interior aspect. (3.5: 1-) /, 
incus; Im, syndesmosis between mal- 
leus and incus; M, malleus; Plm, long 
process of malleus; b, place of insertion 
for muse, tensor tympani; Ma, man- 
ubrium of malleus; a, articular surface 
of incus for the anterior stapes articula- 
tion; PI, long process of incus; Pb, short 
process of incus. 



The exterior form of the incus (Figs. 19 and 20) resembles a tooth 
with two roots and a poorly developed crown. The medial part is called 
the body of the incus, and has at its medial plane a shallow fossa oc- 
cluded by connective tissue. A cone-shaped, 
horizontal process with posterior aspect is 
called the short process; the long process, 
which runs vertically downward, is flexed at 
a right angle at the end. The terminal part 
is distended in the shape of a small button 
and carries the articular surface to connect 
with the incus and the head of the stapes. 
The flexed, button-shaped end of the incus 
stands, so far as history of development is 
concerned, in relation to the long crus, as the 
epiphysis does to the diaphysis, although 
normally their osseous union occurs in utero. 
Should this osseous union fail to take place, 
the lower end of the long crus of the incus 
may appear as an independent part in macer- 
ated preparations. In former times it was 
designated "ossiculum Sylvii." 

The posterior end of the short crus of the 
incus has a flattened surface like a facet. The body of the incus has a 
gable-shaped articular surface corresponding to the impression of the 
articular surface of the malleus. The lateral surface is provided with 
small processes pointing backward and downward, regulating the move- 
ments of the malleus and incus articulation in such a 
way that any inward movement of the malleus takes 
the incus along with it, while the latter may remain 
in a partly or wholly stationary position in any out- 
ward movement of the malleus. 

The stapes (Fig. 21) consists of the plate, the 
crura and the head. The plate is kidney-shaped, the 
hilus pointing downward and forward. The crura 
form hollow grooves of extreme tenderness. The ten- 
don of the stapes muscle is inserted in the posterior 
crus near the head. 

The malleus in the new-born is 7.5-8.5 mm. long; 
the long crus of the incus 6.5, the short one 4.25 mm.; the height of the 
stapes is 3.25 and the length of the plate 2.5 mm. After birth the audi- 
tory ossicles increase by about one-tenth their original size, but the 
ossicles vary in size and shape, the stapes undergoing the greatest 
deviations, especially in regard to position and length of crura, less so 
the incus, and least of all the malleus. 



Fig. 21. 




Right stapes. (3.5 : 1.) 
a, head of stapes; 6, plate 
of stapes; Sta, crura of 
stapes. 



20 THE DISEASES OF CHILDREN 

Both malleus and incus are derived from the first postoral arch, and 
originate from the hindmost section of Meckel's cartilage, from the 
anterior part of which the submaxillary bone is developed as a membrane- 
bone. Stapes and pedicular process as well as the stylo-hyoid ligament 
and the inferior epihyal bone, are descendants of the second postoral 
arch. 

The connection between malleus and incus as well as between incus 
and stapes is usually a simple syndesmosis, positive articulations with 
demonstrable rudimentary articular cavities and accessory ligaments 
having only been found in rare cases. In many animals with an excellent 
sense of hearing (rodents and others) the articular surfaces of malleus 
and incus are joined by osseous growths. 

The stapes is fixed in the vestibular window by an annular ligament 
which imparts to the stapes considerable motility, especially after the 

union between the incus and stapes has 

"Fir 22 

been severed. The manubrium of the 
malleus is completely embedded in the 
tympanic membrane (Figs. 23-25). 

The tympanic membrane is divided 

into two parts : a large one — pars tensa — 

and a small one — pars flaccida (membrana 

Shrapnelli). The former is intimately ad- 

mu Tu herent to the manubrium up to the short 

Right tympanic membrane and auditory process and spread out in funnel-shape 

ZZ^iXZr^tmi^nZ: from this adhesion (Fig. 23). It has a 

5^^S±rT£ rf 3 i«: diameter of 7.5-9 mm. in the new-born 

musculus tensor tympani; Tu, tuba audi- an( J Q f Q,_;Q mm _ j n the adult. The Cen- 

tiva. 

tral and lowest point of the funnel coin- 
cides with the lowest point of the manubrium (umbo). The tympanum 
has three layers; the lowest, which consists of connective tissue (lamina 
propria), shows a combination of radial and circular fibres (stratum 
radiatum, stratum circulare). The radial fibres are particularly well 
developed in the middle of the tympanic membrane and along the 
manubrium, and occasionally form a yellowish white spot at the 
umbo demarkated by rays (pes anserinus). The circular fibres are 
situated medially from the radial fibres and are particularly frequent 
at the peripheral margin of the tympanic membrane (Fig. 23), where 
they occasionally form a grayish-white ring, which is demonstrable 
as early as at the end of the first year, but is more frequently ob- 
served at the clinical examination of old individuals with atrophic 
integument of the auditory canal. The manubrium is surrounded 
by circular fibres and layers of connective tissue which terminate 
in looplike figurations (Fig. 25). The circular connective tissue layers 




ANATOMY OF THE EAR 



21 



Fig. 23. 



which surround the manubrium are of very firm texture and give the 
impression of bones at the otoscopic examination. In this way the manu- 
brium appears much thicker in the picture of the normal tympanic mem- 
brane than would correspond to the actual circumference of the bony 
structure (Fig. 24). In a serous, osmotic 
tympanic membrane, however (suppura- 
tive catarrh of the middle ear) , the con- 
nective tissue layers become transparent, 
and the outline of the manubrium now 
appears narrow and thin in the otoscopic 
picture (Plate VIII, Fig. 1). 

The substantia propria of the tym- 
panic membrane is invested with a layer 
of epidermic epithelium toward the audi- 
tory meatus, this layer being consider- 
ably thicker in the first few months of life 
than in the adult. During the first six 
months there is rather considerable des- 
quamation, and if in the first few weeks 
there is rapid desquamation of the newly- 
developed epidermal surface, there may 
appear small epidermal nodules which 
microscopically are seen to contain cho- 
lesterine crystals and may simulate cho- 
lestoma. No papillae can be recognized 
in the epidermic layer of the pars tensa. 

The medial plane of the substantia 
propria is invested with the tender epi- 
thelium of the tympanic mucosa, the 
greatest part of which is cuboidal, while 
in the basal part of the tympanic mem- 
brane and in the direction toward the 
tubal ostium it is cylindric and in the 
upper part of the membrane frequently 
consists of pavement epithelium. The 
mucous layer of the membrane, in con- 
junction with the lamina propria, forms 
folds and trabecular thickening which, in 
aflat aspect, appear as a dendritically ramified network (Gruber) (Fig. 29). 

The pars flaccida (membrana Shrapnelli), which varies in size from 
a pinhead to a hempseed, has only one layer of the substantia propria 
(Fig. 27), and the arrangement in circular and radial fibres is likewise 
absent (Fig. 27). There are papilla? in the epidermal layer, and the 




Horizontal section through the tympanic 
membrane of a new-born child at the level of 
the manubrium (M). E, epidermis of the ex- 
ternal auditory meatus; sp, substantia pro- 
pria; m, mucosa layer of tympanic membrane; 
a, accumulation of circular fibres at the periph- 
eral end of tympanic membrane. 



22 



THE DISEASES OF CHILDREN 




Picture of normal tympanic membrane. 
M, malleus; Pb, processus brevis; Ps, 
plica superior; Pp, plica posterior; 7", 
incus; R, light spot; It, incisura Rivini. 



Fig. 



layer of mucosa adheres in the first year, and sometimes longer, to the 
ligaments and folds of the mucosa of the upper space of the tympanic 
cavity. 

The stapes muscle (museums stapedius) is situated in the pyramidal 

process, which allows the muscle tendon to 
reach the stapes through its upper end. 
The malleus muscle, or tensor tympani, 
originates in the upper section of the 
musculo-tubal canal. Its tendon embraces 
the processus cochleariformis, traverses the 
tympanic cavity, and thus reaches the 
malleus (Figs. 30 and 31). The stapedius 
muscle is innervated by a branch of the 
facial nerve, the malleus muscle by a branch 
from the trigeminal, one coming from the 
interior pterygoid nerve and the other from 
the otic ganglion. 
The chain of auricular ossicles is supplied with a number of liga- 
ments, one of which encircles in convolutions the manubrium immediately 
below the short process. It originates at the medial surface of the lateral 
attic wall. The manubrium continues 
its course antero-inferiorly to the tym- 
panosquamous fissure. The supero- 
posterior part of this ligament is de- 
scribed as the external malleus ligament 
(ligamentum mallei externum) and the 
antero-inferior part as the internal 
malleus ligament (ligamentum mallei 
anterius) (Fig. 27). 

The incus ligament originates in two 
portions at the external wall of the an- 
trum and is inserted at the posterior end 
of the crus of the incus (Fig. 32). The 
auricular ossicles, as well as their muscles 
and ligaments, are invested with mucous 
membranes forming folds which at some 
places are of regular appearance, and at 
others variously shaped (Figs. 27 and 28) . 

The typical folds of the mucous membrane (Figs. 22, 30, 31 and 32) 
are the following: 

(1) The malleus-incus fold, wrongly designated as malleus-incus 
ligament or as upper malleus ligament. It runs from the upper pole 
of the malleus-incus articulation to the roof of the tympanic cavity; 




Cross section through the tympanic mem- 
brane of a new-born at the level of the 
manubrium. M, manubrium; c, circular 
connective tissue layers encircling the man- 
ubrium; b, vessels of the manubrium; a, epi- 
dermal layer, abundant desquamation of 
epithelium. 



PLATE II. 





Ca 

Fig. 1. Frontal vertical section through the ear of the new- 
born. Mucous tissue (a) in the anterior part of the tympanic 
cavity near where the tube branches off. Enlarged 1.5: 1. b 
tympanic membrane; Te, tegmen tympani; Mae, external audi- 
tory meatus; Ca, internal carotid. 



Fig. 2. Vertical section through the ear of the 
new-born. In the area of the promontory (P) and 
the vestibule (V), the chain of auricular ossicles is 
invested with embryonal mucous tissue (yellow, a), 
which completely fills the entire tympanic cavity. 
Enlarged 1.5 : 1. Mty, tympanic membrane; Ca, 
internal carotid. 





Co Sta 

Fig. 3. Frontal vertical section through the ear of the new- 
born in the area of the antrum (A). Posterior half of section. 
Enlarged 1.5 : 1. The entire space of the middle ear is filled 
with mucous tissue (a), from which the short incus process (7) 
and the stapes (Sta) protrude. A, attic; Css, superior semi- 
circular canal; Co, cochlea; V, trigeminal nerve; VII, facial 
nerve; VIII, auditory nerve. 



Co Hy Me 

Fig. 4. Infant, twelve weeks old. Mucous tissue in 
the epitympanum. Head of malleus (M) completely cov- 
ered with mucous tissue. The lateral (.10 and the medial 
(Am) attic are almost completely filled with mucous tissue. 
The meso- and hypotympanum are already free and passa- 
able. P, Prussak's space; Ala, manubrium; Me, mesotym- 
panum; II y, hypotympanum; Co, cochlea. 



ANATOMY OF THE EAR 23 

(2) The anterior malleus fold. It encloses the anterior malleus 
ligament, the chorda tympani and the long process of the malleus; 

(3) The posterior malleus fold between the manubrium and the 
posterior edge of the tympanic membrane; 

(4) The fold of the chorda; 

(5) The stapes fold. It partially or completely occludes the lumen 
bounded by the crura and plate of the stapes. 

The following belong to the atypical folds : 

(1) A mucomembranous bridge between the tympanic bone and the 
tensor tendon; 

(2) A mucomembranous bridge between the manubrium and the 
long incus process; 

Fig. 26 




Radial (r) and circular (c fibres of the tympanic membrane. Preparation in glycerin. 

(3) Several mucomembranous folds extending from the body of 
the incus to the lateral and medial walls of the tympanic cavity; 

(4) Slender radial mucomembranous bridges, running from the 
stapes to the edge of the fossula fenestrse vestibuli (Politzer). Besides, 
there are small spherical or oblong corpuscles which sometimes occur in 
the tympanic cavity and more frequently in the antrum (Politzer's 
corpuscles) . 

All the folds of the mucous membrane are normally transparent 
like glass, tender and elastic in the living as well as in the fresh prepara- 
tion. In the latter they often become visible at the moment of tearing 
the preparation with a needle. Through catarrhal and other affections 
of the middle ear the folds may become gray, thickened and rigid (chronic 
adhesive process). 

The folds of the mucous membrane represent the remnants of an 
extensive mesodermal tissue (Plate II), which fills the entire tympanic 



24 



THE DISEASES OF CHILDREN 



Fig. 27. 



cavity of the foetus as well as the new-born (Hyrtl, v. Troeltsch). The 
tissues becomes resorbed, as soon as air enters through the Eustachian 
tube, while they will undergo rapid purulent disintegration from inflam- 
mation of the middle ear in the new-born or a few weeks after birth. 
After death the mucous tissue undergoes exceedingly rapid decom- 
position from putrefac- 
tion, filling the t ympanic 
cavity of infants with a 
gelatinous, more or less 
purulent fluid. 

In the normal course 
of development, resorp- 
tion of the mucous tissue 
occurs first in the hypo- 
tympanum, while the mu- 
cous membrane of the 
tympanic cavity remains 
permanently thicker in 
the hypotympanum than 
in any other area of the 
middle ear, abundant 
folds and lymphadenoid 
tissue being not infre- 
quently found in children 
four to five years old. It 
has even been proposed 
to designate the latter as 
tympanic tonsils. The 
lymphatic tissue is pre- 
served a little longer in 
the folds of the mucous 
membrane in the shape 
of small-celled infiltrates 
(Anton). Resorption of 
the mucosa deposits in 
the mesotympanum is 
usually complete in the sixth to eighth week. The mucous membrane 
of the tympanic cavity becomes thin, but the folds permanently persist. 
The mucous tissue of the tympanic cavity is preserved longest in the 
upper space, which, in most cases, is still traversed by large numbers of 
reticularly ramified mucous bridges. These are sometimes demonstrable 
as late as the first and, in arrested development and under-nutrition, 
the second year. 




Horizontal section through the tympanic membrane of the new-born 
at the level of Shrapnell's membrane (Mf) and the malleus-incus artic- 
ulation (M, I). The lateral attic (la) is filled with embryonal 
mucous tissue. O 0, annulus tympanicus at the level of the inci- 
sura Rivini; LI, lateral ligament of malleu3; Mf, membrana flaccida 
Shrapnelli. 



ANATOMY OF THE EAR 



25 



The tympanic cavity is supplied with blood from three arterial 



areas : 

(1) Internal maxillary artery, which sends a branch, the tympanic 
artery, into the tympanic cav- 
ity by way of the tympano- 
squamous fissure ; 

(2) Branchlets of the in- 
ternal carotid and the posterior 
auricular. The stylomastoid 
artery, which fuses with the 
chorda tympani and is a small 
branch of the ascending pharyn- 
geal artery, reaches the tym- 
panic cavity through the tym- 
panic canal; 

(3) Several branches of 
the middle meningeal artery. 

All these vessels form a 
very dense vascular net, anas- 
tomose with each other, and 
sometimes communicate either 
direct (Fig. 45) or through the 
artery of the internal auditory 
meatus with the vessels of the 
labyrinth (Politzer). 

There are two vascular 
areas in the tympanic cavity: 

(1) A network of capilla- 
ries near the posterior margin 
of the manubrium, which 
fuses with the blood vessels 
of the external meatus at the 
upper pole of the tympanic 
membrane; 

(2) Circular capillaries 
at the peripheral margin 
of the tympanic membrane, 
which exclusively emanate from the blood vessels of the middle ear. 

The vessels of the manubrium are connected by a dense radial 
network with peripheral circular vessels. 

The lymph vessels of the middle ear are supplied by the area of the 
deep cervical lymph glands, the bundle of submaxillary glands and the 
retropharyngeal glands. On the other hand, the lymph vessels of the 




Horizontal section through the tympanic cavity (Ty) of 
a new-born at the level of the short process (P6) and the 
chorda tympani (Ch). Af.malleus; /.incus; Mt, membrana 
tympani; E, epidermis of the external auditory canal. 



26 



THE DISEASES OF CHILDREN 



/ 



middle ear do not communicate with the mastoid glands on the planum 
mastoideum which contains the lymph vessels of the occipital portion of 
the scalp. 

The tympanic cavity is supplied with sensitive fibres by the tym- 
panic nerve (Jacobson's), which originates in the area of the glossopha- 
ryngeus and, ascending from the otic ganglion, reaches the tympanic 
cavity, proceeds along the promontory upward to the geniculate gang- 
lion and, fusing in the tympanic cavity with the sympathetic fibres of 
the carotid plexus, finally dissolves in the plexus tympanicus. Secretory 

and sensitive fibres are left behind 

Fig. 29. .... , 

in the geniculate ganglion, where 
\ they j oin the descending facial and 

\ leave it again as chorda tympani 

:> (Figs. 31 and 32). The latter 

takes an arcuate course through 
,| ^ut the tympanic cavity, arrives be- 
tween malleus and incus anteriorly 
at the tympanosquamous fissure, 
through which it leaves the tym- 
panic cavity without giving off 
any branches. 

3. The Topography of the 
Middle Ear. — The ligaments and 
mucous folds of the auricular 
ossicles and tympanic cavity are 
for the most part situated in the 
border region of the meso- and 
epitympanum, causing slight per- 
forated or fissured connections, 
even in normal conditions. The 
base, or lowest point of the epitym- 
panum, in the natural position of 
the head, is formed by Shrapnell's membrane. The communication be- 
tween the meso- and epitympanum may be entirely destroyed if the nor- 
mal folds of the mucous membrane become enlarged and thickened through 
catarrhal inflammations. Should this lead to suppurative inflammation 
of the upper tympanic space, the pus will be unable to escape into the 
mesotympanum and gradually gravitate toward Shrapnell's membrane, 
which will eventually be perforated. Isolated perforation of that mem- 
brane is, therefore, always a sign of suppuration of the middle ear con- 
fined to the upper space of the tympanic cavity. Insertion of malleus 
and incus materially reduces the free space of the attic, and there occurs 
a cleft between the lateral attic wall and the auricular ossicles; and a 




/ 



y 



Dendritic network (D) of the medial surface of the 
tympanic membrane (Mt). 



ANATOMY OF THE EAR 



27 



Fig. 30. 



similar cleft between the latter and the medial tympanic wall. The 
first cleft is called the lateral, and the second the medial attic. 

The portion of the upper space between the tympanic cavity lying 
in the projection of the membrana 
flaccida is called Prussak's space 
(Plate II, Fig. 4). It is bounded 
exteriorly by Shrapnell's membrane 
and the free border of the osseous 
attic wall, superiorly by the lateral 
ligament of the malleus, interiorly or 
medially by the neck of the malleus, 
inferiorly by the short process of 
the malleus. Prussak's space opens 
anteriorly and posteriorly into the 
attic. 

The clefts bounded by the mal- 
leus folds and the tympanum are 
called tympanic pockets (Figs. 30, 31 
and 32). The chorda pocket lies 
between the posterior tympanic fold 
and the chorda fold. The anterior 
tympanic pocket and the chorda pocket are closed at the top, while the 
posterior tympanic pocket communicates at the top with Prussak's space. 




Right lateral wall of the tympanic cavity, interior 
aspect. Ch, chorda tympani; Mt, tympanic mem- 
brane; Ps, superior malleus fold; M, malleus; A, 
tympanic antrum; C, carotid; T, tuba auditiva; 
Mtt, tensor tympani muscle. 



Fig. 31. 




Mtt 



VII 



Mt Mtt 



Left lateral wall of the tympanic cavity, 
interior aspect. Course of the chorda tym- 
pani. (l l i of natural size.) VII, facial 
nerve; Ch, chorda tympani; Mt, mem- 
brana tympani; Mtt, tensor tympani 
muscle; M, malleus. 



Fig. 32. 




Right lateral wall of tympanic cavity, in- 
terior aspect. (1J4 of natural size.) Ch, 
chorda tympani; T, tuba auditiva; M, 
malleus; J, incus; .4, tympanic antrum; 
Mt, membrana tympani. 



This connective aperture, however, is frequently obliterated by catarrhal 
affections, but owing to its small size, even when present, it plays no 
material part in the downward drainage of the upper tympanic space. 



28 



THE DISEASES OF CHILDREN 



4. The Tympanic Antrum. — The antrum is a cavity the size of a 
small pea, which is inserted between the tympanic cavity and the mastoid 
process. Its upper wall is formed by the tegmen antri, the lateral wall 
by the free border of the superior and posterior auditory canals (anterior 
wall of the mastoid). At the lateral wall there is the fossa incudis, to 
which the posterior incus ligament adheres. 

The osseous lateral semicircular canal protrudes at the medial plane 
in the shape of an oblong crest. Posteriorly, the antrum terminates in 
the shape of a spherical cavity with cribriform perforation of the wall. 
The gaps correspond to the ostia of the mastoid cavities which, in normal 

Fig. 33. 




Mae 

Flat section through antrum tympanicum (A) and the mastoid process. Ss, sigmoid fossa; a, upper pole 
cell; Mae, external auditory meatus; Sgu, squamous portion of the temporal. 

cases, communicate with the antrum. The latter is invested with a tender 
mucous membrane and traversed by a few thin mucous folds which 
frequently contain Politzer's corpuscles. It can at once be demon- 
strated with a normal preparation that a colored fluid, introduced 
into the antrum, penetrates into all the mastoid cells. The antrum is 
already developed in the new-born and situated superficially, owing to 
the complete absence of the mastoid. The medial part of the lateral wall 
at birth, and sometimes a few months later, contains cartilaginous rem- 
nants. Up to the end of the second year the osseous walls remain ex- 
tremely thin, and this explains why in juvenile cases of mastoiditis 
subperiosteal abscesses and osseous fistulse develop very rapidly in the 
mastoid region. 



ANATOMY OF THE EAR 



29 



5. The Mastoid Process. — The mastoid region of the new-born is 
flat, the process itself is absent; antrum, digastric fossa and the stylo- 
mastoid foramen are superficially situated. The mastoid process devel- 
ops with the increase in size of the sternocleidomastoid muscle and is 
primarily to be regarded as a muscle process, serving to enlarge the fold 
of insertion for the muscle. The development of the mastoid, therefore, 
occurs simultaneously with the rapid increase in thickness of the sterno- 
cleidomastoid, which takes place as soon as the infant tries to carry or 
balance its head independently. A really important development of 
the mastoid, however, will not commence before the end of the first 
year, when the infant commences to walk and attempts to exercise its 
balancing power, so that the gradual development of the mastoid is 



Fig. 34 




Lateral surface of temporal bone of twelve-year-old child. 

intimately connected with the general physical development. Any 
disease arresting the ability of controlling movements of the head and 
attempts at walking will interfere with the development of the mastoid. 
At the age of one year the structure of the latter corresponds to that of 
the other cranial bones. The outer layer is rather thin, and its interior is 
entirely filled with diploic tissue. At the age of two years the normal 
development of the air cells commences. The growth of the mastoid is 
practically completed at puberty, but there will still be increase in thick- 
ness of the outer layer and a further extension of the cells in the vicinity 
of tne sinus and apex. 

At the lateral surface of the mastoid there are the small mastoid 
fossae, which deepen toward the auditory meatus, the mastoid triangle 
and the antrum triangle. At the border of the external auditory meatus, 



30 



THE DISEASES OF CHILDREN 



there is the suprameatal spina. The mastoid is bounded by the crista 
temporalis inferior toward the squama. At the normal position of the 
head the crista is about at the level of the base of the medial cranial fossa ; 
its posterior end is broadened and elevated in the shape of a flat eminence 
(tuberculum supramastoideum) . The upper and medial parts of the 
lateral mastoid surface are smooth except for an ethmoidal punctation 
near the mastoid fossa. Short periosteal layers of connective tissue run 
into the small mastoid fossae. The rough apex of the mastoid is the 
field of insertion for the sternocleidomastoid. At the medial plane of 
the mastoid there is the digastric fossa, which carries at its medial border 
the pedicular process and the lower aperture of the facial canal (foramen 
stylomastoideum) . 



Fig. 35. 




Pm 



Mae 

Temporal bone of fourteen-year-old boy with congenital stenosis of the exterior meatus (Mae). Ip, incisura 

parietalis; Pm, mastoid process. 



The border between the mastoid and squama in the new-born 
is the squamomastoid fissure which divides the mastoid into a small 
antero-posterior and a large postero-inferior part, and occasionally per- 
sists either completely or partly until the end of the second year in the 
shape of a fissure directed towards the base of the auditory meatus. 
On the other hand, the intramastoid fissure runs from the incisura 
parietalis to the mastoid apex, and is a variety of the first-named fissure. 

The fissures are filled with connective tissue and have plenty of 
blood-vessels which serve for the better nutrition of the rapidly growing 
bony parts. Remnants of these fissures are not infrequently demon- 
strable in old age in the shape of clefts or indentations filled with par- 
titions of the periosteum and sometimes conduct mastoid veins outside. 
In rarer cases, the vascular canals will persist after obliteration of the 



ANATOMY OF THE EAR 



31 



fissure, arranged in a vertical line in accordance with the direction of 
the fissure. Occasionally any one of the fissures may persist completely 
(Fig. 36). 



Fig. 36. 




Temporal bone with persistent squamomastoid fissure. 



The surface layer of the fully developed mastoid is thickest at its 
lateral surface and becomes rapidly thinner toward the apex. At that 



Fig. 38. 



Fig. 37. 




Vertical section through a pneumatic mastoid (p). 
p', antrum cells; C, exterior (thick) layer; .4, antrum 
tympani. 




Vertical section through a diploic mastoid (AT). The 
external corticalis (C) is thin at the apex (C) ; the 
inner corticalis (C")' is likewise thin. Pz, zygomatic 
process. 



place, and at the medial wall, where it is often as thin as paper, it fuses 
with the compact portion of the petrous bone (Fig. 38). 

The mastoid process contains air-carrying, pneumatic cells or diploe 



32 



THE DISEASES OF CHILDREN 



Fig. 39. 



and, accordingly, a distinction is made between the pneumatic, the 
diploic and the mixed mastoid. The pneumatic mastoid (Fig. 37) may 
be large- or small-celled, and it is only exceptionally that it is made up 
of a few large cavities. The pneumatic cells are invested with a tender, 
pale mucosa and communicate with each other by apertures. Occlusion 
of some or all of the communicating apertures, and therefore partial 
isolation or obliteration of mastoid cells, may occur from inflammatory 
affections. Large cells occur at the apex and near the sigmoid sinus 
(Fig. 33) of the pneumatic mastoid, while in the vicinity of the antrum 
the cells are usually small (Fig. 37). The diploic mastoid contains 

plenty of blood and lymph spaces (Fig. 38). 
The mixed form is a combination of the 
two others, in which either the centrally situ- 
ated pneumatic part is invested with a diploic 
layer, or the upper portion of the mastoid is 

pneumatic, the apex dip- 
loic, or the reverse. In 
the juvenile mastoid, 
which is always diploic, 
the development of 
pneumatic spaces means 
a secondary change in 
'"^ which the diploic tissue 
is displaced by the 
pneumatic and finally 
resorbed. If this dis- 
placement and resorp- 
tion is complete, the 

Norma! pneumatic tissue of the mastoid, o, bony trabeeula; m, mucous COIlSeQUenCe will bp a 
membrane. " 

purely pneumatic mas- 
toid ; if some diploic parts remain, the consequence is a mixed mastoid. If 
no areolas are formed at all, the mastoid will be diploic even in the adult. 
In advanced age, the osseous tissue of the mastoid may be either exceed- 
ingly thin (osteoporosis) or very dense (osteosclerosis). These changes 
are merely incidental to advancing age and do not signify any aural 
affection. In cases of chronic suppuration of the middle ear, however, 
a more or less extensive condensation of the bony structure in the interior 
of the mastoid will occur, amounting to pathological osteosclerosis of the 
mastoid. In some of these cases the bone turns as hard as ivory and 
completely loses all its cavities (eburnation of the mastoid). 

According to size and form, we have to distinguish between (1) the 
normal mastoid; (2) the small mastoid; (3) the large, bullous mastoid; 
(4) the flat mastoid; and (5) the pointed mastoid. 




PLATE III. 



Css 



Csl 




Dr Dc v 



Fig. 1. Diagram of membranous labyrinth. 
Superior portion : Css, superior semicircular canal ; 
Csl, lateral semicircular canal; Csi, inferior semi- 
circular canal; As, superior ampulla; Al, lateral 
ampulla; Ai, inferior ampulla; Sus, superior utric- 
ular sinus; Ru, anterior utricular sinus (recessus 
utriculi); Sui, inferior utricular sinus; U, utricle. 
Inferior portion: 5, saccule; Cus, utriculosaccular 
canal; De, ductusendolymphaticus; Se, saccus en- 
dolymphaticus; Dr, Ductus reuniens; Cv, ves- 
tibular cul-de-sac of cochlea; Cc, cupolar cul-de- 
sac of cochlea; Dcv, vestibular section of cochlea; 
Dc\, basal convolution of cochlea; Dei, medial con- 
volution of cochlea; Dec, apical convolution of 
cochlea. 



Sus 




Fig. 2. Topography of osseous capsule of 
labyrinth (Lo) and of the membranous labyrinth 
(diagram). Av, vestibular aqueduct; Mat, internal 
auditory meatus; Ac, cochlear aqueduct; St, scala 
tympani; Mts, membrana tympani secundaria; 
Sla, stapes; Ru, recess of utricle; Csi, inferior 
semicircular canal; Cpv, cisterna perilymphatica 
vest.; Sv, scala vestibuli; Dc, cochlear duct. 



Sta Mts St 




Fig. 3. Ramification of nerves of the mem- 
branous labyrinth and its nerve-endings (dia- 
gram). Nvest, vestibular nerve; Nc, cochlear 
nerve; Gvs, superior vestibular ganglion; Gvi, in- 
ferior vestibular ganglion; Gsp, spiral ganglion; 
Nun, utriculoampullar nerve ; Nu, nervus utriculi; 
Nas, superior ampullar nerve; Nat, lateral ampullar 
nerve; Nsa, nervus sacculo-ampullaris : A's, ner- 
vus saccularis; .Vn?', nervus ampullaris inf.; Cas, 
crista ampullaris sup.; Cal, crista ampullaris lat.; 
Cat, crista ampullaris inf.; jl/«, maculi utriculi; 
Ms, maculi sacculi; Oc, organ of Corti. 



Nil Ms 



ANATOMY OF THE EAR 



33 



The small mastoid is mostly diploic and is found more frequently 
in the female sex and individuals with weak musculature. The bulbous 
mastoid is always pneumatic. Expansion of the areolae downward 



Fig. 40. 




Normal temporal bone with conical mastoid process; oval cross section (12-year-old child). 

Fig. 41. 




Bullously enlarged (distended) normal mastoid process. 

may occasion flattening or even convex protrusion of the cortical layer 
into the area of the incisura mastoidea (Figs. 41 and 6). Statistics 
of examinations of a large number of skulls (Zuckerkandl) have 
given the following results: pneumatic mastoids were found in 

Vol. VI— 3 



34 THE DISEASES OF CHILDREN 

40 per cent., diploic in 20 per cent., and mixed in 40 per cent, 
of the cases. In the majority of cases, both mastoids of the same 
individual were of the same internal structure. 

V. THE INTERNAL EAR. 

The internal ear consists of (1) the membranous labyrinth, with 
nerve-end organs; (2) the osseous capsule of the labyrinth; and (3) the 
auditory nerve and its ganglia. 

The membranous labyrinth develops through ligation of the 
labyrinthine vesicle from the embryonal epidermis of the parietal region. 
The embryonal, epithelial, labyrinthine vesicle gradually assumes a 
more and more complicated shape, and the origin of the completely 
developed labyrinth from a primary structure, the labyrinthine cyst, 
can only be understood from the fact that all spaces of the labyrinth are 
in communication with one another. 

Taking the course of development into consideration, we distin- 
guish a pars superior and a pars inferior in the membranous labyrinth 
(Plate III). The pars superior consists of the utricle and the recess of 
the utricle (sinus utriculi anterior), superior sinus and inferior, three 
ampullae, and three semicircular canals. The ampullae and the recess 
of the utricle are invested with nerve epithelium of a characteristic 
form (Figs. 42 and 43). The nerve-end places of the ampullae are called 
cristas ampullares, and the one situated in the recess of the utricle is 
called macula utriculi. 

The semicircular canals, the ampullae, and their nerve-end places 
are named according to their position in the cranium. Thus, there are 
the frontal (antero-superior), the horizontal (medio-external) , and the 
sagittal (postero-inferior) canals. 

From this the following nomenclature is derived for the ampullae 
and the nerve-end places: ampulla superior (frontalis, anterior) and 
crista ampullaris superior; ampulla lateralis (horizontalis, media) and 
crista ampullaris lateralis; ampulla inferior (sagittalis, posterior) and 
crista ampullaris inferior. 

The pars inferior comprises the sulcus and the membranous cochlear 
duct (ductus cochlearis). The latter is funnel-shaped, with its narrow 
end pointing upward, which communicates through a fine canal (canalis 
utriculo-saccularis) with the utricle and fuses with the ductus endo- 
lymphaticus. This duct proceeds through the vestibular aqueduct to 
the posterior surface of the petrous bone, where it terminates in an 
amplified sac (saccus endolymphaticus), enclosed in a kind of pocket 
formed by the dura. The sac has minute apertures, through which it 
communicates with the extradural spaces, while in the endodural direc- 
tion it is completely closed. It connects with the external aperture of 



ANATOMY OF THE EAR 



35 



the vestibular aqueduct and often encroaches, downward and outward, 
for several millimetres upon the medial wall of the sigmoid sinus. 

The saccule communicates with the membranous cochlear duct 
through the ductus reuniens, which inosculates into the cochlear duct, 
as the small intestine does into the large, forming at the same time a 
cul-de-sac bordering posteriorly upon the cochlear duct (caecum vestib- 
ulare). The membranous cochlear duct is spirally convoluted (Figs. 
43 and 44). Its initial part (vestibular section) is 4 mm. long and is 
curved on a large radius. The remaining part of the cochlear duct is 



Fig 42. 




Sta Cpv Ca 



Vertical section through the labyrinth. Topography of the ampulla. (12: 1.) Cas, crista ampullaris 
sup.; As^ ampulla superior; p, perilymphatic connective tissue; U, utricle; Av, vestibular aqueduct; De, endo- 
lymphatic duct; Ai, ampulla inferior; Cai, crista ampullaris inferior; Cpv, cisterna perilymphatica vestibuli- 
Sta, stapes; I, mucous fold of stapes; Al ampulla lateralis; Cal, crista ampullaris lateralis. 

curved on a lesser and gradually diminishing radius and is called the 
body of the cochlea, while the amplified blind end, which is situated in 
the apex, is called the cupola (caecum cupulare). The lumen of the 
cochlear duct increases from base to apex and has two and three-fourths 
convolutions in the body of the cochlea. The last quarter of the convo- 
lution is formed by the cupola. Stretched out the membranous cochlear 
duct is about 30 mm. long. 

The pars inferior has two nerve terminations: (1) the macula sacculi 
and (2) the papilla basilaris cochleae (Corti's organ). 

The Nerve Termination of the Labyrinth.— The pars superior of 



36 



THE DISEASES OF CHILDREN 



the labyrinth contains: (1) crista ampullaris superior, (2) crista ampul- 
laris lateralis, (3) crista ampullaris inferior, and (4) macula utriculi. 
The inferior portion contains: (1) macula sacculi and (2) macula basi- 
laris cochleae (Corti's organ). 

Arranging the above according to the homology of their histological 
structure, there will be three groups: (1) belonging to the semicircular 
canal: crista ampullaris superior, lateralis, and inferior; (2) belonging 
to the vestibule (vestibular sacs) : macula utriculi, macula sacculi ; and 
(3) belonging to cochlea: papilla basilaris cochlea? (Corti's organ). 



Nua 




Frontal vertical section through the vestibulum. (10 : 1.) V, utricle ; Ma, macula utriculi; Cpr, peri- 
lymphatic vestibular cistern; At, inferior ampulla; Mts, secondary membrane of the tympanum; Dc, cochlear 
duct; Sta, stapes; VII, facial nerve; Nua, utriculo-ampullar nerve. 



Although there are considerable differences in function and the 
finer details of structure, there is one uniform ontogenetic basis for 
these three groups. 

At certain places of the embryonal labyrinth, the simple epithelium 
changes into sensory or nerve epithelium, which comprises two groups 
of cells: (1) the hair-cells, which are the sensory cells proper; they are 
barrel-shaped and provided with a number of the finest hair-processes 
10-15 m long and 8-12 /x wide, arranged like a brush. The protoplasm 
of each nerve-cell contains the end of a primitive fibre, spirally convo- 
luted or in screw shape, of the nerve bundle to which it belongs (Kolmer). 
The large cystic nucleus does not communicate with any of the nerve- 
fibres. The position of the hair-cells in the nerve epithelium is preserved 



ANATOMY OF THE EAR 



37 



by specially formed and geometrically arranged prop-cells. There is 
only one kind of prop-cell in the cristae and maculae, while in Corti's 
organ various prop-cells are differentiated and can be demonstrated in 
the histological picture. Furthermore, there is one common charac- 
teristic in that all the nerve-end places are provided with formed, 
resistant corpuscles, with which the hair-processes communicate. The 
hair-processes in the cristae ampullares and maculae, and to a certain 



Fig. 44. 

Sv 2 Da Gsp Svi 



Dei 




Axis section through the cochlea of a twelve-year-old child. Mai, internal auditory meatus; Nc, 
cochlear nerve; Gsp, spiral ganglion; Dcv, cochlear duct of the vestibular section; Dei, cochlear duct of 
the basilar convolution; Dc2, cochlear ductof the medial convolution; Stv, scala tympani of the vestibular 
section; Sti, scala tympani of the basilar convolution; Svv, scala vestibuli of the vestibular section;. Svi, scala 
vestibuli of the basilar convolution; St>2, scala vestibuli of the medial convolution; H, helicotrema. 



extent also those of Corti's organ, converge toward the median line of 
the nerve-end places. In the cristae ampullares they are collected in a 
cartilaginoid corpuscle (capula terminalis) having the shape of a cap or a 
saddle and situated at the convex surface of the cristae. The hair-proc- 
esses of the macula utriculi and macula sacculi fuse with the otolithic 
membrane which carries the otoliths. 

The cupola as well as the otolithic membrane have indications of 
a very subtle striation corresponding to the prolongation of the hair- 
processes. The otoliths consist of calcium carbonate and calcium 
phosphate; the smallest have a diameter of 2-5 n and are of irregular 



38 THE DISEASES OF CHILDREN 

or spherical shape; the larger ones have a diameter of 5-25 n and indi- 
cate a hexagonal type. 

The nerve-end place of the cochlea is covered by the membrana 
tectoria (cortical membrane), which is homologous to the cupola of the 
ampullae and to the otolithic membrane of the vestibular sacs. 

The arrangement of the hair-processes and the parts making de- 
mand upon the latter indicates that the physiological stimulations of 
all nerve-end places of the labyrinth are merely dependent upon the 
causation of movements (pressure changes in the sense of increased 
or diminished demands, vibrations). These movements are imparted 
to the hair-processes, and the movements of the latter are the stimulation 
for the nerve-cells. The stimulation is taken up by the nerve-end fibres 
inclosed in the nerve-cells, and conducted centrally to the brain. 

I. HISTOLOGICAL STRUCTURE OF THE NERVE-END CELLS OF THE 

LABYRINTH 

1. Histological Structure of the Cristae Ampullares. — Each crista 
ampullaris (Fig. 42) forms a crest bulging into the ampullar lumen 
vertically to the longitudinal axis. The fissure caused by this position 
is filled out by the nerve bundles and the connective tissue accompany- 
ing the same. The nerve epithelium is bounded against the surround- 
ing cell structure by a line of cylindrical epithelium and a longitudinal 
sulcus (sulcus cristae). The vertical section of the cristae has the shape 
of a crest or bud, covered by the cupola, which, like the entire crista, 
protrudes into the free ampullar space. 

2. Maculae of the Vestibular Sacs. — Both maculae are situated at 
the level of the epithelial wall of the sacs. The macula sacculi lies within 
the saccule itself, while the macula utriculi lies in a recess of the utricle 
(recessus utriculi, sinus utricularis anterior). The macula utriculi (Fig. 
43) will be seen at the lateral recess wall in the fresh preparation as a 
white spot in the shape of a heart, and larger than a millet-seed. Ex- 
teriorly it is covered by the bundles of the nerve of the utricle. At the 
endolymphatic surface it carries the otolithic membrane together with 
the otoliths. The base of the macula utriculi is turned toward the 
perilymphatic vestibular cistern. 

The macula sacculi is smaller than the macula utriculi and forms an 
oval in the direction of the longitudinal axis of the saccule. It is situ- 
ated in the middle wall of the saccule, with its base turned toward the 
osseous vestibular wall. 

3. Papilla Basilaris Cochleae (Corti's Organ). — The structure of 
Corti's organ can only be considered in conjunction with that of the 
membranous cochlear duct (Fig. 44) . 

The membranous cochlear duct (Fig. 44, 45) is spread out between 



PLATE IV. 



Css 



Ai Csi Ss 




Mai Nai 










- c 



M 



Fig. 1. Osseous labyrinth of a two- 
months-old child. Css, superior semi- 
circular canal; Csi, inferior semicircu- 
lar canal; Csi, lateral semicircular ca- 
nal; Co, commissure of the semicircu- 
lar canal; Mai, internal auditory 
meatus. 



Ft Hy 



Fig. 2. Horizontal section through the temporal bone of a 
twelve-year-old child. Inferior half of section. Natural size. Mai, 
internal auditorymeatus; Nai, canal for nerv. ampullaris inf.; V, 
vestibulum; Ai, inferior ampulla; Csi, inferior semicircular canal; 
Ss, sigmoid sulcus; C, external corticalis; Mae, external auditory 
meatus; Hy, hypotympanum; Fc, fenestra cochleae; Co, cochleae; Cc, 
carotid canal. 



Mae 




Pz 



Sta 



Csi 



Mai V 




Fig. 3. Horizontal section through temporal bone of a twelve- 
year-old child. Superior half of section. Natural size. Cc, carotid 
canal; isp, lamina spiralis; Pm, fossa mandibularis; Pz, zygomatic 
process; Sta, stapes; Mae, external auditory meatus ; Csi, lateral semi- 
circular canal; Csi, inferior semicircular canal; V, vestibulum; Mai, 
internal auditory meatus; Co, cochlea. 



Fig. 4. Lateral wall of labyrinth. Vestibu- 
lar aspect. One-year-old cbiid. 1 ' 4 ' natural 
size. V, vestibule; Css, lateral semicircular 
canal; Fe, fenestra vestibuli; Co, commissure of 
semicircular canals; -4s, superior ampulla. 



ANATOMY OF THE EAR 39 

the lamina spiralis ossea and the external osseous cochlear wall. It 
effects the division of the perilymphatic cochlear space into the scala 
vestibuli and the scala tympani, being inserted in the endolymphatic 
canal (which was originally called the scala media). The cochlear duct 
being axially connected w r ith the osseous cochlear wall more or less in 
the shape of a ledge, and peripherally in the shape of a plane, it follows 
that the cross section shows a triangle with an acute axial, an acute 
superior and an obtuse lateral angle. It is opportune, therefore, in 
describing the membranous cochlear duct, to distinguish between three 
walls: (1) the basilar wall (membrana basilaris), (2) the external (periph- 
eral) wall, and (3) the superior wall (membrana vestibularis, Reissner's 
membrane). The membranous wall is the result of a combination of 
epithelial (endolymphatic) and mesodermal (perilymphatic) elements 
of the three distinct walls just described. 

4. Membrana Basilaris. — The base of the membrana basilaris 
(Figs. 44 and 45) is formed by most minute, spiral, anuclear connective 
tissue fibres, which run in an axioperipheral direction (membrana pro- 
pria). It fuses axially with the crista spiralis, peripherally with the 
spiral ligament, the ligamentum spirale. The latter is covered toward 
the scala tympani with a nuclear tympanic membranous layer. Its 
upper plane, which is turned toward the endolymphatic space, carries 
the epithelial end-apparatus of the cochlea (Corti's organ) (Fig. 45), 
which is composed of regularly arranged, polymorphous epithelial cells 
and consists, like the other labyrinthine end-places, of hair-cells and 
prop-cells. The radial vertical section of Corti's organ has the shape of a 
hilly crest. The medial part of Corti's organ is formed by two columnar 
cells (Corti's columns). Their broad base rests upon the lamina propria, 
which close against each other at the top in gable-form. At the two 
sides of the columnar base, which turn toward each other, there are the 
two basilar cells which morphologically belong to the columnar cells and 
are supported by Deiters's prop-cells. These are arranged axially from 
the columns in palisade fashion, with rapidly flattening cylindrical epi- 
thelium, which is continued into the cuboidal epithelium of the neigh- 
boring sulcus spiralis internus. Peripherally from the columnar cells 
there are three or four rows of Deiters's prop-cells, and furthermore 
three kinds of surrounding epithelia: (1) cuboidal epithelium (Bottcher's 
cells), (2) cylindrical epithelium (cells of Claudius), and (3) high cylin- 
drical epithelium. The latter terminates in convex form and descends 
from the distal row of Deiters's prop-cells in a semicircle toward the 
basilar membrane (Hensen's arch). These three epithelial layers are 
finally followed up by the cuboidal epithelium of the sulcus spiralis 
externus. 

Each row of prop-cells is accompanied by a row of hair-cells, so 



40 



THE DISEASES OF CHILDREN 



that axially from Corti's columns there is one row of hair-cells, while 
peripherally there are three to four. The hair-processes of the hair-cells 
are in uninterrupted connection with the membrana tectoria (Corti's 
membrane) and grow right through the border membrane (membrana 
reticularis). The primitive fibres, emanating from the external hair- 



Fig. 45. 




Axis section through the basilar convolution of the cochlea. Pbc, papilla basilaris cochleae; Psp, spiral 
promontory; Stv, stria vascularis; Nc, nervua cochleae; Gsp, spiral ganglion; a-v, anastomosis between the 
blood-vessels of the petrous bone and the labyrinth (Politzer). 

cells, traverse the tunnel space, fuse with the fibres coming from the row 
of internal hair-cells, and, running through the lamina propria, arrive 
in the fissure of the lamina spiralis ossea, where they form the cochlear 
nerve with the aid of the marrow they have acquired. 

The crista spiralis is situated on the upper surface of the lamina 
spiralis ossea in the axial angle of the cochlear duct. It consists of a lower 
section lined with connective tissue and an epithelial upper section. The 



PLATE V. 




Ss 



Fig. 1. Frontal section through the nucleus of 
the labyrinth in the region of the semicircular 
canals and antrum (A). Enlarged 13<j : 1. Aqu, 
aquteductus vestibuli; Co, commissure of the semi- 
circular canals; Csl, lateral semicircular canal; o, 
upper edge of petrous bone; A, antrum; S, squama of 
temporal bone; Mae, external auditory meatus; 
Cvii, facial canal; Fj, jugular fossa; Csi, inferior 
semicircular canal. 




Fig. 2. Topography of the osseous semicircular canals. Left tem- 
poral bone of a six-year-old boy. Natural size. Css, superior semi- 
circular canal; Mai, internal auditory meatus; Co, commissure of semi- 
circular canals; Csi, inferior semicircular canal; Ss, sigmoid sulcus; o, 
upper edge of petrous bone. 



Css 




■Mae 



Fig. 3. Window of labyrinth with vestibule. 
Petrous bone of a six-months-old infant. Frontal 
section. Enlarged 1.5 : 1. V, vestibulum; Pc, 
proc. cochleariformis; Stu, semicircularis tubae; 
Fv, fenestra vestibuli; P, promontory; Mae, ex- 
ternal auditory meatus; Fc, fenestra cochlea?; Ai, 
inferior ampulla; Co, commissure of semicircular 
canals; Css, superior semicircular canal. 



Cvn 




P Fc 



Fig. 4. Medial and posterior walls of 
vestibule. Vertical section through tem- 
poral bone of a six-months-old infant. 
Enlarged 1)4 '■ 1- Te, tegmen tympani; 
As, superior ampulla; V, vestibule; Css, 
superior semicircular canal; Ai, inferior 
ampulla; Fc, fenestra cochleae; P, promon- 
tory; Fv, fenestra vestibuli; Cvii, facial 
canal; a, sound in the vestibular section 
of the aquaxluctus vestibuli. 



Css Fsu 



Csi 




Csl 



Fig. 5. Posterior wall of the vestibule. Left temporal bone of a six-months-old 
infant. Vertical section. Enlarged \Yy : 1. Fxu, fossa subarcuata; Te, tegmen tym- 
pani; S, squamous part of temporal bone; .In, superior ampulla; .1, antrum: .1/. 
lateral ampulla; V, vestibule; Ai, inferior ampulla; Csl, lateral semicircular canal; 

Csi, inferior semicircular canal; Css, superior semicircular canal. 



ANATOMY OF THE EAR 41 

latter fuses partly with the epithelium of the sulcus spiralis internus, 
and partly with the epithelial layer of the membrana vestibularis (Reiss- 
ner's membrane). Corti's membrane originates at the place where 
Reissner's membrane separates from the crista spiralis. 

5. The External Wall. — The base of the external wall (Fig. 45) is 
formed by the ligamentum spirale. The epithelial wall is independent up 
to the prominentia spiralis, forming cubicocylindrical epithelium which 
invests the sulcus spiralis externus. The vascular stria, in which the 
epithelial and connective-tissue components of the cochlear duct are 
intimately united, extends upward from the prominentia spiralis to the 
upper angle of the cochlear duct. 

6. The upper wall of the cochlear duct (membrana vestibularis, 
Reissner's membrane) extends between the upper and axial angles 
(Figs. 44 and 45). It is extremely tender and consists of two layers of flat 
cells with mostly prominent nuclei. According to embryological de- 
velopment, the inner layer is of epithelial, the external connective- 
tissue layer of mesodermal origin. 

The labyrinth is supplied with blood-vessels by the internal auditory 
artery. We are indebted to Siebenmann for valuable investigations as 
to the vascular supply of the labyrinth. 

II. THE OSSEOUS LABYRINTH (OSSEOUS CAPSULE) AND THE PERILYM- 
PHATIC TISSUE (PERILYMPHATIC CAPSULE OF THE LABYRINTH) 

In describing the osseous capsule of the labyrinth (Plates IV-VII) 
it was not feasible to adopt the division offered by the membranous 
labyrinth into superior and inferior sections. The osseous labyrinth 
should be divided into three sections, which can be done without con- 
straint, as follows: (1) semicircular canals, (2) vestibule, (3) cochlea. 

General. 

The osseous capsule of the labyrinth develops from a cartilaginous 
layer which protects the labyrinthine vesicles exteriorly as early as the 
end of the second month of embryonic life. In the course of develop- 
ment the cartilaginous layer grows over the labyrinth with an increasing 
curvature, enveloping it toward the auditory nerve, and, while thus ad- 
vancing toward the future internal auditory meatus, forms the carti- 
laginous capsule of the labyrinth. The osseous capsule of the labyrinth 
is the result of ossification of the cartilaginous embryonal capsule. In 
the new-born it is still to a certain extent independent of the other parts 
of the petrous bone and isolated through surrounding cartilaginous 
remnants (islands) and large marrow spaces. The latter sometimes 
persist until the second year, and the cartilaginous islands are under 



42 THE DISEASES OF CHILDREN 

certain circumstances still present until the thirtieth year; nevertheless, 
intimate connections of the osseous compacta of the capsule with that 
of the petrous bone always occur at an early period, so that in the ma- 
jority of cases there can only be a question of cavities of the osseous 
labyrinth, but not of a disconnected osseous labyrinth from the second 
year onward. It is only exceptionally that the petrous bone is pervaded 
for a greater length of time by large cavities (marrow spaces or pneumatic 
cells), thereby more or less isolating the osseous capsule. 

The Vestibule. — The vestibule is a roomy, empty space of irregular 
formation (Plates IV-VII). For purposes of description, it is convenient 
to assume a cuboidal form with six walls. The lateral wall contains the 
vestibular window, which is occluded by the plate of the stapes and 
leads into the middle ear (Plate IV, Fig. 4) . Closely above the vestib- 
ular window and next to the lateral pole there is the hook-shaped end 
of the crista vestibuli, which runs over the upper and anterior walls 
toward the inferior one, where it gradually diffuses. The crista vestibuli 
is divided by the vestibulum into a large, superior (recessus ellipticus) 
and a small, inferior part (recessus sphaericus). The upper wall (Plate 
IV, Fig. 3) and the inner wall (Plate V, Fig. 4) of the vestibulum have 
no apertures whatever, while the anterior wall (Plate V, Fig. 3) contains 
the area cribrosa sacculi. It is situated in the centre of the recessus 
sphaericus, which is destined to receive the saccule. Medially, the slit- 
like terminal aperture of the vestibular aqueduct adjoins the recessus 
sphaericus (Plate V, Fig. 4). The aqueduct terminates in the vestibulum 
with a tangent aperture, in about the same way as the ureter communi- 
cates with the bladder. The posterior wall of the vestibulum (Plate V, 
Fig. 5) contains the terminal aperture of the lateral ampulla and the 
lateral semicircular canal. At the juncture of the posterior and superior 
walls, the terminal ostia of the upper ampulla and the commissure of 
the semicircular canal (the common crus of the superior and posterior 
semicircular canals) are situated. 

The terminal aperture of the ampulla of the posterior sagittal 
semicircular canal is situated at the lower plane of the vestibulum. The 
crista vestibuli diffuses at the lateral margin of the ampullar ostium, 
while in the external part of the lower plane the vestibular base unites 
with the primary and secondary spiral osseous layers of the cochlea. 
The vestibular cul-de-sac of the membranous cochlear duct is situated 
in a fossula of the vestibulum. Right in front of this place the fissure 
commences which, bounded by both lamina? spirales ossese, effects the 
communication of the scala tympani with the scala vestibuli, as can be 
seen in the macerated preparation. This fissure is bridged over and 
closed by the membrana basilaris of the membranous cochlear duct. 
The area cribrosa superior is visible at the upper end of the crista ves- 



ANATOMY OF THE EAR 



43 



tibuli. The latter forms the passage-way for the fibres of the utriculo- 
ampullar nerve to leave the bone, and, after these fibres have traversed 
the vestibulum itself for a short distance, they arrive at their nerve-end 
places. 

The Osseous Semicircular Canals. — The position of the osseous 
semicircular canals (Plates IV-VII) coincides with that of the membranous 
canals which terminate in them. The diamater of the osseous canals 
is about eight times greater than that of the membranous ones, while 
the circumference of the osseous ampulla exceeds but slightly that of 
the membranous ampulla. The consequence is that the osseous canals 
are less sharply marked against the osseous ampullae than the membra- 



Css 



Fig. 46. 




Cavity of the bony labyrinth. Css, canalis semicircular superior; Csl, canalis semicircular lateralis; 
Cst, canalis semicircular inferior; .4s, ampulla superior; .4/, ampulla lateralis; Ai ampulla inferior; Ac, aqua?- 
ductus vestibuli; Re, recessus ellipticus; Rs, recessus sphsericus; Fv, fenestra vestibuli; Fc, fenestra cochlea?; 
^4e, aquaeductus cochleae; Cv , cochlea — vestibule; Cb, cochlea — basal turn; Cm, cochlea — second turn; Cc, 
cochlea — gyrus semitertius. 



nous canals are against the membranous ampulla?. The average figures 
in the new-born are the following: diameter of the osseous canals 1.25 
mm., length of frontal canal 12 mm., length of horizontal canal 13 mm., 
length of sagittal canal 14 mm. 

The Osseous Cochlea. — The osseous cochlea (Plates IV, VI, VII) 
consists of the following parts: vestibular section (6 mm. long), body of 
cochlea, apex of cochlea. The vestibular part is the connecting tube 
between vestibulum and body of cochlea. 

The body of the cochlea has 23^ convolutions and terminates in a 
flat cupola. The radius of curvature diminishes from the cochlear base 
to the apex. The convolutions are differentiated as basal, medial, and 
apical, and are separated from one another by osseous walls. The nerve- 
fibres coming from Corti's organ diffuse in the axial part of the cochlea 
(modiolus) and reach the internal auditory canal through the tractus 



44 THE DISEASES OF CHILDREN 

spiralis foraminosus (Fig. 45). There is a double lamella (lamina spira- 
lis ossea primaria), originating from the modiolus at the median height 
of each convolution, which receives the nerve-fibres coming from Corti's 
organ. The lamina spiralis divides every cochlear convolution into an 
upper (scala vestibuli) and a lower compartment (scala tympani). The 
interposition of the membranous cochlear duct completes the separation. 
The lamina spiralis ossea primaria is confronted with the secondary 
osseous spiral lamella (lamina spiralis ossea secundaria) in the vestib- 
ular section and in the lower half of the basal convolution, both lamellae 
uniting as they pass into the lower wall of the vestibulum. At the upper 
end of the medial convolution, the lamina spiralis ossea loses its line of 
insertion at the modiolus, and protrudes in the shape of a spirally curved, 
pointed hook (hamulus) into the apical convolution (Plate VI, Fig. 5; 
Fig. 45). The aperture hereby occasioned between the cochlear axis 
and the hamulus (helicotrema) allows the two compartments to com- 
municate axially from the membranous cochlear duct. Resection of the 
peripheral cochlear wall from the modiolus exposes the wall at the end 
of the cochlear cupola as a lamellar terminal surface of the modiolus, 
and this part of the external wall of the cupola is called the lamina 
modioli. The cochlear aqueduct, which opens into the lower surface of 
the petrous bone, originates in the scala tympani near the cochlear 
window. It forms a connecting tube of the perilymphatic spaces with 
the intradural space, into which it opens. 

The nerve-fibres in the lamina spiralis ossea are spiral, and arranged 
in a backward direction. The ganglionic duct (Rosenthal's duct) branches 
off in the modiolus, following the spiral course of the lamina spiralis ossea. 

III. TOPOGRAPHY OF THE NERVE-END PLACE OF THE LABYRINTH 

(Plates III, VI, VII) 

The surfaces of the cristae ampullares form, similarly to the semi- 
circular canals and ampullae, a right angle against each other. Corre- 
sponding to the wall of the sulcus, the macula utriculi and the macula 
sacculi are slightly convex. Constructing a medial plane for both will 
show the following result: with erect position of the head, the macula 
sacculi appears approximately frontal and vertical, the macula utriculi 
runs vertically against the macula sacculi, slightly descending from 
outward and upward to inward and downward. 

IV. TOPOGRAPHY OF THE INTERNAL EAR 

The membranous labyrinth is parietally fixed in the spaces of the 
osseous labyrinth (Figs. 42-45). This fixation is accomplished by the 
perilymphatic connective tissue which invests the osseous surface with 
an endosteal layer and the membranous labyrinth with a subepithelial 



ANATOMY OF THE EAR 45 

layer, the perilymphatic ligaments extending between both layers. The 
spaces of the osseous labyrinth are not completely filled at any place by 
the membranous labyrinth. While at some places there are only cleft- 
like perilymphatic interspaces (at the ampullse, the upper wall of the 
utricle, etc.), there are at other places large perilymphatic spaces which in 
extent far exceed the regional endolymphatic spaces, Such spaces are 
the following: 

(1) Along the semicircular canals: perilymphatic canals. 

(2) In the vestibule in the projection of the lateral vestibular wall 
and stapes : the vestibular cistern (cisterna perilymphatica vestibuli) . 

(3) In the cochlea in the shape of cochlear canals. 

The perilymphatic spaces of the semicircular canals are isolated 
from the vestibular cistern by connective-tissue layers. The scala 
vestibuli is distended at the vestibular end of the cochlear duct, reach- 
ing into the vestibular cistern and communicating at the apex of the 
cochlea with the scala tympani through the helicotrema. The lower 
cul-de-sac of the scala tympani is situated at the membrana tympani 
secundaria. The facial nerve (Plate VII, Fig. 1) terminates superficially 
in the internal auditory meatus in its S-shaped course. The utriculo- 
ampullar nerve lies below and travels outward and backward. The 
sacculo-ampullar nerve sends an isolated branchlet into the canaliculus 
ampullse inferior. The cochlear nerve occupies the lowest position and 
runs forward and downward. 

The endolymphatic spaces communicate with each other, also with 
the lymph fissures of the dura through the vestibular aqueduct, and 
indirectly with the extradural spaces of the posterior cranial fossa. The 
perilymphatic spaces are in direct communication with the intradural 
spaces through the cochlear aqueduct and through the cleft-like lymph 
spaces along the nerve branches of the internal auditory canal. 

In infants and children up to the end of the second year many parts 
of the osseous labyrinth extend to the surface of the petrous bone, as, 
for instance: 

1. The external crus of the lateral semicircular canal protrudes at 
the middle of the antrum wall; 

2. The vestibular section of the cochlear duct is situated below the 
promontory. 

3. The eminentia arcuata corresponds to the vertex of the superior 
semicircular canal, the fossa subarcuata to the hollow space bounded by 
the same canal (Plate V, Fig. 5). 

4. The commissure of the semicircular canals is distinctly recog- 
nizable at the posterior surface of the petrous bone. 

5. The upper surface of the sagittal semicircular canals protrudes 
crest-like at the posterior surface of the petrous bone. 



46 THE DISEASES OF CHILDREN 

6. The upper part of the basal cochlear convolution causes a flat- 
convex eminence at the superior petrous surface. 

7. The external apertures of the two aqueducts and of the hiatus 
spurius of the facial canal lie at the superior petrous surface. 

The osseous layer covering the osseous labyrinth increases in density 
in proportion to the increase in size of the petrous bone, as development 
proceeds. The development from the time of puberty onward proceeds 
as follows : 

Topographically important places which remain unchanged are 
the prominence of the lateral semicircular canal and the promontory. 
The vertex of the frontal semicircular canal, which in the new-born is 
often covered with an osseous lamella so thin and transparent that the 
membranous canal may often be seen through it in the fresh preparation, 
is far away from the eminentia arcuata in the adult, sometimes as far 
as several millimetres. 

Commissure, sagittal canal, and superior crural pole are far removed 
from the upper surface of the petrous bone and covered with a thick 
compact bone. The ostia of the hiatus spurius and vestibular aqueduct 
are grown over by osseous lamellae which impart a cleft-like form to 
the canal-shaped ostia. The cochlear aqueduct is considerably increased 
in length and has formed a gaping triangular ostium. The internal 
auditory canal is considerably elongated in the course of growth. The 
fundus of the auditory canal either remains unchanged or becomes ampli- 
fied, while the external aperture of the internal auditory canal (porus 
acusticus internus) is usually narrower than in the new-born. The total 
post-embryonal increase in size of the labyrinth is about 18 per cent. 

V. EIGHTH NERVE 

The fibres of the eighth nerve (Plates III and VII) terminate in 
the hair-cell protoplasm of the labyrinthine nerve-end places. The 
peripheral branches of the auditory nerve are interrupted by a gang- 
lionic mass composed of bipolar cells. This mass forms three vestibular 
ganglia, — superior, inferior, and spiral. 

The utriculoampullar nerve terminates in the upper vestibular 
ganglion, the sacculo-ampullar nerve in the lower vestibular ganglion, 
and the cochlear nerve in the spiral ganglion. The latter is situated in 
the canalis ganglionaris of the cochlea; the two vestibular ganglia, 
which are centrally connected with each other, are situated deep in the 
internal auditory canal. The union of the fibres emanating from the 
vestibular ganglia separates the eighth nerve centrally from the ganglia 
into two branches (roots), the vestibular and the cochlear. The nervus 
intermedius, which is situated in the internal auditory meatus over the 
vestibular nerve, does not communicate with the eighth and terminates 



PLATE VI. 



Co Epm Ma Epl 




Css 



Csl A 

Fig. 1. Attic (Ep), vestibufe (V), antrum 
(A), and cochlea (Co). Right temporal bone of a 
fourteen-year-old child. Co, cochlea; Epm, medial 
attic; Epl, lateral attic; I, incus; Ma, malleus; 
M, mastoid process; A, antrum; Csl, lateral semi- 
circular canal; V, vestibule. 



Css 




Cst Fe Pv 



Fig. 4. Topography of labyrinth (external aspect). Enlarged 134: 1. Fc, 
cochlear window; Pv, vestibular section of cochlear duct. For further abbrevia- 
tions see Fig. 2. 



Lm 

HP V Fc 

Fig. 5. Labyrinthine nucleus of 
petrous bone of a three-year-old child. 
Spaces of labyrinth opened from with- 
out. Enlarged 114 : 1. Css, superior 
semicircular canal; Fc, fenestra cochlea?; 
Csl, lateral semicircular canal; V, vesti- 
bule; Csi, inferior semicircular canal; 
P, promontory; H, helicotrema; Lm, 
lamina modioli. 





Fig. 3. Topography of labyrinth (posterior aspect). Enlarged \\i '■ 1. 
Ac, cochlear aqueduct; o, superior edge of petrous bone, Fj, jugular 
fossa. For further abbreviations see Fig. 2. 



Mai 



Fig. 2. Temporal bone of a two-year-old child. Projection 
of the membranous labyrinth (in superior aspect). Enlarged 
IK ; 1. HYII, Hiatus spurius of the facial canal; Css, superior 
semicircular canal; Csl, lateral semicircular canal; U, utricle; 
Ss, sigmoid sulcus; De, ductus endolymphaticus; Csi, inferior 
semicircular canal; S, saccule; Dc, cochlear duct. 




Coc 



Fig. (i. Modiolus (Mo). Enlarged 
1)4 ! 1. b, cerebral surface of petrous 
bone; Co\, basal convolution; Cos, medial 
convolution; Coc, apical convolution; La, 
labyrinthine nucleus (compact bone); a, 
spongy paralabyrinthine zone: d, canal- 
iculus ampullae inferioris; Mai, internal 
auditory meatus. 



ANATOMY OF THE EAR 47 

in the geniculate ganglion. Joined with the facial, the acoustic arrives 
at the crus cerebri at the lateral margin of the pons. The vestibular 
nerve runs medially from the restiform body to the medulla oblongata. 
Its descending part (radix of the spinal acusticus) extends down to the 
region of the hypoglossal nucleus and terminates in the small-celled 
vestibular nucleus (nucleus parvicellularis vestibularis). Deiters's 
nucleus, which is also called the nucleus of coordination, is besides in- 
timately related to the cerebellum, the nerve-nuclei of the ocular muscles, 
and the motor nerves of the nuchal musculature. 

The vestibular, centrally from its nucleus, passes through the sub- 
stantia reticularis into the optic thalamus. The further course of the 
vestibular nerve is not definitely known. 

A direct communication of the fibres of the vestibular nerve with the 
cerebral cortex has not been demonstrated, but it is assumed that its 
vestibular course, after one or two interruptions, terminates in the pos- 
terior portion of the cortex of the parietal lobe (Munk's sensory sphere). 
It is also assumed that this cortical region plays a part in space orien- 
tation. 

The cochlear nerve arrives laterally from the restiform body in 
the crus cerebri and the ventral and dorsal cochlear nuclei (nucleus 
accessorius and tuberculum acusticum). The cochlear fibres traverse 
centrally the fourth ventricle and, after crossing the median line, play 
the principal part in the formation of the lateral loop. Part of the fibres 
terminate in the superior olivary body. The centripetal course of the 
cochlear nerve is again interrupted in the looped nucleus, in the posterior 
corpus quadrigeminum and the geniculate ganglion. The central end 
runs across the posterior part of the inner capsule in the cortex of the 
temporal lobe (probably the first temporal convolution, gyrus trans- 
versa). The striae acusticse arise from the tuberculum acusticum and 
take partly a homolateral, partly a central course, crossing each other. 

Each temporal lobe is supplied from both auditory nerves. In 
central affections of the cochlearis, therefore, there can never be a ques- 
tion of unilateral deafness, as the affection, whether partial or total, 
must necessarily be bilateral. 



II. PHYSIOLOGY OF THE EAR 

Two sensory apparatuses are combined in the function of the ana- 
tomical entity of the ear, — the auditory organ in a physiological sense 
to perceive the sound, and a sensory organ for orientation in space, 
perception of position, of accelerations, and indirectly for the mainten- 
ance of the body equilibrium. This sensory organ is called the static 
organ (Breuer) or static labyrinth. 

The sound-perceiving organ is the papilla basilaris cochleae (Corti's 
organ), which is situated in the cochlea. It enables a person of normal 
hearing to perceive a great variety of sounds within the scale of high 
and low limitation, noises, and mixtures of sounds and noises. The 
lower acoustic limit of the tuning-fork is 12-16 (double) vibrations, 
the upper one 35,000 to 40,000. The sound vibrations are carried by 
the air from the sound source into the ear. 

Sound is conducted to the cochlea in three ways : 

(1) Air conduction, in which we distinguish meato-tympanic and 
pharyngo-tympanic conduction. The meato-tympanic route ap- 
peals most to the auditory sense. The sound waves pass through 
the external auditory meatus into the tympanic cavity by means 
of the tympani membrane and the chain of auricular ossicles, and 
thence into the cochlea. The efficacy of the pharyngo-tympanic 
route has been demonstrated by Politzer's experiments showing that 
the sound waves pass through the Eustachian tube into the tym- 
panic cavity and thence into the cochlea as in the meato-tympanic 
conduction. 

(2) Bone Conduction. — The sound waves originating in the air 
and those produced by directly applied vibrating bodies impart the 
vibrations to the cranial bones, whence they are transmitted to the 
cochlea. There are a cranio-tympanic and a cranio-labyrin thine conduc- 
tion, according to Bing. In the former the waves imparted to the bone 
are retransformed into air waves in the tympanic cavity, whence they 
reach Corti's organ in the same way as in air conduction. In the 
cranio-labyrinthine conduction the waves imparted to the cranial bones 
exert a direct effect upon the cochlea without being transformed in the 
tympanic cavity. In bone conduction sound is normally perceived only 
through the cranial bones, although it has been observed that young 
individuals may sometimes perceive sounds from bones further distant 
(scapula, radius, etc.). 

(3) Cartilage conduction, which represents a certain form of bone 
conduction. 

48 



PLATE VII. 



Nvn 
Mt 




Fig. 1. Topography of the ear. Mt, 
tympanic membrane; iVvn, facial nerve; 
M, malleus; I, incus; A, antrum; S, squa- 
mous part of temporal bone; Csl, lateral 
semicircular canal; C'si, inferior semicir- 
cular canal; Css, superior semicircular 
canal ; Co, commissure of semicircular ca- 
nal; Aqu, aquaeductus vestibuli; Ss, sig- 
moid fossa; Sta, stapes; Nv, vestibular 
nerve; Nc, cochlear nerve; Iv, impressio 
trigemini; C'oi, basal convolution; C02, 
medial convolution; Coc, apical convolu- 
tion; Np, large superficial petrosal nerve; 
T, tubaauditiva; Gg, geniculate ganglion. 



Nvn 




Fig. 2. Topography of the facial nerve. TVvii, 
facial nerve; jVviii, auditory nerve; Gg, geniculate 
ganglion; Csl, lateral semicircular canal; A, an- 
trum; Mst, stapedius muscle; Pro, promontory; 
Fe, fenestra cochlea?; Sta, stapes; C, carotid; Np, 
large superficial petrosal nerve. 



Sta Fc 



Pro 





Fig. 3. Topography of the cochlea 
(Co). Tsp, traetus spiralis foraminosus; 
Mai', internal auditory canal; CC, carotid 
canal; Stu, semicanalis tubse; Stt, semica- 
nalis tensoris tympani. 



Fig. 4. Topography of vestibule of the an- 
trum. S, squamous portion of temporal bone; 0, 
cerebral surface of petrous bono; V, vestibule; h, 
cerebellar surface of petrous bone; Csl, lateral semi- 
circular canal (terminal aperture in the vestibule); 
Ai, inferior ampulla; Pro, promontory; Sta, stapes; 
Ty, tympanum; Mae, external auditory meatus; Psl, 
prominentia semicirc. lateralis; .1, tympanic an- 
trum. 



PHYSIOLOGY OF THE EAR 49 

THE THEORY OF HEARING. THE PHYSIOLOGY OF THE SOUND- 
CONDUCTING APPARATUS 

According to Helmholtz's theory, or hypothesis, of resonance, 
the end-organ within the cochlea is capable of analyzing a sound im- 
pression into its component parts. Acoustico-analytical properties of 
this kind are also possessed by string instruments, and especially by 
the piano. We may confidently assume that the cochlea as well as the 
piano has a number of strings of varying size which are attuned to certain 
sounds. The assumption that the fibres of the basilar membrane are 
indeed attuned to certain sounds is confirmed by the fact that they are 
of different lengths in different parts of the cochlea. The basilar fibres 
of the cochlea, 15,000 to 20,000 in number according to Hasse-Retzius, 
increase in length from base to apex. 

The crucial point in Helmholtz's theory is the supposition that a 
certain sound causes only certain strings to vibrate, or a certain group 
of sounds a certain group of strings. These strings are always those 
which, according to their length, are attuned to the sounds conducted 
to the ear. The string fibres of the cochlea being enclosed in the 
basilar membrane, there can be no question of vibration of single fibres, 
but only of certain radial portions of that membrane. Helmholtz's 
theory easily and completely explains the phenomenon of floating sounds, 
secondary sound manifestations, the sound gaps and sound islands 
observed in many cases of oral affections and deaf-mutism. It pays 
due regard to intermediate sounds, combination, differential, summa- 
tion, variation and intermittent sounds. 

Wundt has expressed the opinion that each sound reaches the central 
organ in two ways: (1) through the cochlea, for which he adopts Helm- 
holtz's theory, and (2) through a direct incitement of the fibres of the 
auditory nerve by vibrations imparted to the cranial bones, circumvent- 
ing the cochlea, which means by way of skull conduction. Wundt's 
opinion is based upon Ewald's communication on the hearing ca- 
pacity of animals without labyrinths (pigeons) and on a number 
of observations made on patients with unilateral destruction of 
the labyrinth. These observations, however, have not withstood 
criticism, and to-day it is considered an established fact that a sound- 
impression can only lead to physiological excitation of the auditory 
nerve, and thereby conscious perception, by way of the cochlea and 
Corti's organ. 

Hermann attributed to the ear the ability of perceiving each period 
as sound. Later he adopted Helmholtz's theory, adding, in order to 
explain intermittent sounds, that each string fibre and each definite 
section of Corti's organ was only in connection with a definite nerve- 
cell (Zahlzelle). But since it was demonstrated that the intermittent 

Vol. VI— i 



50 THE DISEASES OF CHILDREN 

sounds are either of physical origin or else differential sounds, his cell 
theory has become superfluous (Schafer). 

An independent theory of hearing has been proposed by Max Meyer. 
The vibrations imparted to the cochlea by the middle ear are transmitted 
to a shorter or longer piece of the basilar membrane according to the 
objective intensity of the sound, which would be subdivided into a 
number of sections vibrating more or less rapidly. Each definite section 
corresponds to a definite sound, the length of the section determining 
the subjective intensity of the sound, and the frequency of vibrations 
its position in the scale. A similar idea of static waves in the basilar 
membrane is contained in the theory of ter Kuile. Finally, Ewald thinks 
that each sound imparted to the ear causes the basilar membrane to 
vibrate along its entire length, subdividing the same into a number of 
static waves. The perception of sound is effected by the totality of 
these static waves, — Ewald's sound picture. Each sound has a charac- 
teristic sound picture. Ewald has based his views upon a large number of 
excellent and exact observations on vibrating rubber membranes. In 
order to do the greatest possible justice to the anatomical conditions, 
he constructed rubber membranes the size of the cochlear basilar mem- 
brane and graphically reproduced his sound pictures. 

THE SENSE OF HEARING IN THE NEW-BORN 

The ability of hearing in the new-born is very deficient. The ex- 
ternal auditory meatus is not permeable, and the spaces of the middle 
ear are nearly filled with gelatinous tissue. The surface of the tympanic 
membrane is uneven, and the membrane itself is thick. 

Sound conduction is, therefore, considerably interfered with both 
in the external and middle ear. Such an impediment occurring in the 
adult from diseased conditions would considerably diminish the auditory 
acuity, reducing it to perhaps one or two metres in ordinary conversa- 
tion, and this distance will probably represent the auditory acuity of 
the new-born. 

Motor reaction upon sound-perceptions in the new-born has been 
demonstrated during the first two weeks, the earliest time recorded 
being the fourth day (Preyer). 

Normal auditory acuity develops in the course of the first few weeks 
with the gradual resorption of the connective-tissue deposits in the middle 
ear and the progressive development of the membranous auditory 
meatus into a freely permeable, air-filled passage. 

It is an important requirement for the normal function of the ear 
that all the spaces of the middle ear be full of air and that the pressure 
in these spaces entirely coincides with the pressure from without. The 
normal mucous membrane of the tympanic cavity absorbs small quan- 



PHYSIOLOGY OF THE EAR 51 

tities of oxygen and it is necessary, therefore, from time to time to 
renew the air present in the middle-ear spaces, which means ventilation. 
This ventilation is effected by the reflex or intentional act of deglutition, 
which opens the Eustachian tube and allows air to penetrate through it 
into these spaces. In the absence of reflex deglutition or in pathological 
changes of the tube which prevent its opening in deglutition, there will 
be considerable changes in the tympanic membrane and interference 
with hearing owing to partial or complete resorption of the air in the 
middle-ear spaces. 

THE PHYSIOLOGY OF THE STATIC LABYRINTH (APPARATUS OF THE 
SEMICIRCULAR CANALS AND VESTIBULE) 

Taking into consideration the cellular structure of the nerve-end 
places of the labyrinth, the method of their arrangement, and the fact 
that they are provided with active factors (cupola, otolithic membrane, 
Corti's membrane), it will be understood that the physiological stimu- 
lation for all the nerve terminations must necessarily consist in motion 
(molecular motion, waves, vibration, oscillation, percussion). Corti's 
organ is only responsive to acoustic waves and, accordingly, admits of 
vibratory motion in its position in the cochlea. Any such contingency 
is out of the question for the vestibular nerve terminations (macula 
utriculi, macula sacculi) as well as for the ampullar ones (crista? am- 
pullares) . 

Corti's organ serves the perception of sound, and the mere considera- 
tion of the anatomical structure of the cristae and maculae forces us to 
the conclusion that the vestibular and ampullar nerve terminations are 
not expected to transmit the perception of sound. 

Flourens's discovery, in 1828, that experimental injury of the semi- 
circular canals in pigeons was followed by vertigo and disturbances of 
equilibrium, was of fundamental importance for a knowledge of the 
function of the vestibular apparatus. Meniere, in 1861, found apoplec- 
tic vertigo and equilibrial disturbance to have been caused by a hemor- 
rhage of the labyrinth. Kreidl, in 1887, experimentally demonstrated 
the influence of gravitation upon the otolithic apparatus of crabs. 
Verworm, in 1891, published his important investigations on equilib- 
rium and the otolithic organ of the ktenophorae. Karl L. Schaefer 
demonstrated, in 1894, that invertebrate animals (without semi- 
circular canals) do not suffer from rotatory vertigo, and that the 
latter does not occur, in frog larvae for instance, until the semi- 
circular canals have completely developed. Alexander and Kreidl, in 
1901, found that congenital arrest of equilibrium in the dancing mouse 
was caused by anomalies of development in the vestibular sacs and 
their nerves. 



52 THE DISEASES OF CHILDREN 

Theories on the Functions of the Labyrinth 

The first to elaborate a useful theory, on the ground of anatomical 
and experimental facts, was Goltz. According to his theory, the nerve 
terminal organs of the semicircular canals are organs of equilibrium, 
although it does not entirely exclude the participation of the labyrinthine 
nerve-end places in the function of hearing. The introduction of the 
conception "organ of equilibrium" is due to Goltz 's theory. 

According to Goltz, there is an independent ciliating motion of the 
hair-processes which entertain endolymphatic waves. 

Ewald, in his interpretation of the function of the semicircular 
canals, agrees with Goltz and speaks of "Goltz's sensory organ." Be- 
sides, however, he assumes the existence of a second otolithic (stato- 
lith^) apparatus. According to Ewald, they both serve in the percep- 
tion of movements of the head and body, and indirectly the maintenance 
of equilibrium. The most important part of Ewald's theory, however, is 
the establishment of the conception of the "tonus labyrinth." The nor- 
mal labyrinth, according to this theory, has an influence upon the tonus of 
the entire voluntary musculature, including the stabile equilibrium of the 
entire body, and the conception of the tonus labyrinth leads without re- 
straint to an understanding of the muscle reflexes due to the labyrinth. 

Ewald's theory of looking upon the labyrinth as an organ for main- 
taining or regulating the tonus is undisputed, and the idea of the laby- 
rinth playing a part in maintaining or controlling the equilibrium can be 
simply and clearly deduced from its tonus-regulating effect. 

Delage looks upon the labyrinth as an organ for the perception of 
position and movements of the head, a theory which branches over to 
that of Mach-Breuer. The latter has been carefully built up on the 
basis of anatomical and experimental facts. Accordingly, the semicircu- 
lar canals are organs for the perception of positive and negative angle 
accelerations, while the otolithic apparatus (vestibular apparatus in 
the narrower sense) is intended for the perception of positive and nega- 
tive straight-lined accelerations. The organism is, therefore, tri-axially 
provided for through the three semicircular canals in regard to angular 
acceleration, while straight-lined accelerations are only bi-axially cared 
for by the two maculae of the vestibular sacs; and this refers not only 
to man, but to all terrestrial mammals. Swimming and flying animals 
possess a third nerve terminal with otoliths, which is situated at the periph- 
eral end of the cochlear duct in a section homologous to the vestibular 
sacs (lagsena and macula lagsense). 

It was Breuer who proposed the now generally accepted term of 
"static labyrinth" to designate both the semicircular canals and the 
vestibular sacs. 



PHYSIOLOGY OF THE EAR 53 

Before entering upon the question of physiological function of the 
normal human labyrinth in ordinary life, it is necessary to explain why 
it is difficult to understand this sensory apparatus and to demonstrate 
its function. 

There are three causes: 

(1) The higher organs of special sense are distinguished by easily 
recognizable functions which are strictly differentiated. So far as the 
lower organs of special sense are concerned, there are transition stages. 
Thus, under given circumstances, it may be difficult to decide whether 
a certain perception is due more to the organ of taste or of smell. On 
the other hand, the perceptions emanating from the static labyrinth, 
whatever theory may be adopted, possess no characteristic points which 
could not, at least partially, be transmitted in a similar form by other 
organs of special sense, especially the eye, and also by artificial or deep 
sensations (skin, muscle, articulation). We are, therefore, compelled to 
remove the labyrinthine kernel from the entity of perceptions by special 
methods of observation or special arrangements of examination. We 
have to recognize and exclude all perceptions transmitted by the eye as 
well as superficial and deep sensations. 

(2) The second cause for the difficulty in demonstrating the func- 
tions of the labyrinth lies in the fact that the vestibular nerve has no 
direct communication with the cerebral cortex. The perceptions con- 
ducted centrally through the vestibular nerve become our conscious 
property mostly or exclusively by way of reflexes and their psycho- 
physiological sequelae. 

(3) Finally, the following point presents itself for consideration: 
The various pathological conditions of the static labyrinth must be 
deduced from the various forms of the reflex excitability of the labyrinth, 
and we have consequently to distinguish between the normal, the path- 
ologically exaggerated, the pathologically diminished, and arrested 
(negative) excitability of the static labyrinth. 

The Functions of the Normal Apparatus of the Semicircular Canals and 
Vestibule at Physical Rest and in Motion 

Delage's fundamental experiments have shown that the perception 
of the body position or orientation on the perpendicular is not materially 
changed if all skin and articular sensations are excluded so far as may be 
possible (firmly tying down in oblique position). In diving, the upward 
force of the water counteracts the gravity of the body. Nevertheless, 
we retain a distinct and correct perception of up and down under water 
with closed eyes and without tactile orientation. Both observations lead 
to the assumption of the presence of a special sensory organ regulating 



54 THE DISEASES OF CHILDREN 

the equilibrium. Further experiments compel us to look for this organ 
in the head and finally lead to the recognition of its identity with the 
static labyrinth. In proof of this assumption, James's experiment has 
been frequently cited, in which disorientation was observed in deaf- 
mutes under water. It would be very necessary, however, to subject 
these observations to further tests. 

At the instigation of M. Sachs, R. Barany and myself examined 
the psycho-physiological significance of the statolithic apparatus for 
normal individuals and deaf-mutes as to orientation in space, and found 
that there is no difference between these two classes as to the recognition 
of the perpendicular. It may be assumed that the stimulations of the 
statolithic apparatus are only of slight importance, if any, for forming a 
conception of the perpendicular in normal individuals. 

It is chiefly through the communication of the vestibularis with 
the cerebellum that the static labyrinth is enabled to act as an organ for 
maintaining and controlling equilibrium. The preservation of the nor- 
mal muscular tonus is equivalent with normal stability of the human 
body. The centre of perception of motion and position, however, is not 
situated in the cerebellum, but in the cerebrum — in the foci of the central 
convolutions (Munk's sensory sphere) . With these, however, the vestib- 
ularis is only in indirect communication. 

Generally speaking, affections of the semicircular canals cause such 
manifestations as are otherwise elicited by experimental stimulation, 
such as nystagmus, vertigo, and disturbances of equilibrium. Our 
present knowledge of the symptomatology of the affections and destruc- 
tion of the semicircular canals is already considerable, but we know 
much less about the symptoms due to isolated affection of the vestibular 
apparatus. These consist of equilibrial disturbances without vertigo, 
impairing the stability of the body. The destruction of the entire laby- 
rinth, perhaps even the destruction of the vestibular sacs, leads to changes 
in the tonus of the body musculature. In cases of this kind there are 
hallucinations of labyrinthine character. Thus, we are justified in speak- 
ing of ocular disturbances contingent upon the function of the labyrinth, 
and the disturbances of equilibrium following upon optic and motor 
phenomena are referable to a reaction upon the labyrinth. Finally, 
there are disturbances of the sense attitude to be considered, such as 
feeling larger or smaller, heavier or lighter. 

Coordination and subordination are matters whose regulation pre- 
supposes activity on the part of the vestibular apparatus. 



III. EXAMINATION OF THE EXTERNAL AUDITORY CANAL 

AND MIDDLE EAR 

i. OTOSCOPIC EXAMINATION 

If the conditions for observation are favorable and the auditory 
canal is of ample width, it may be possible to survey the entire length of 
the latter and the tympanic membrane without any further preparation 
or instruments. To institute a methodical examination of the external 
and internal ear, however, a reflector and ear-speculum are necessary. 
The reflector consists of a concave mirror, perforated in the centre, of 
7.5 cm. diameter and 16 cm. focal distance. An oval aperture for in- 
spection is preferable to a round one. The reflector is fastened with a 
band or an elastic metal rim over the operator's forehead, but may also 
be attached to a frame or support which is held with the teeth. The 
ear-specula are made in various shapes and sizes, either from hard rubber 
(Politzer) or metal. Gomperz has introduced a very short speculum for 
otoscopic examination of infants during the first weeks of life, which 
does excellent service. White cloud-light is sufficient for purposes of 
examination. Among the artificial light sources, the uncovered Auer 
lamp is still the simplest and best. The lamp is placed behind the patient 
slightly above the head, and the ear to be examined is turned away from 
the light. 

The first step is to illuminate the entire aural region by means of 
the reflector. If there are no changes at the auditory meatus, the concha 
is gently drawn backward and upward, and the speculum inserted with 
a slight rotatory movement until it reaches the border line between 
the cartilaginous and osseous canals, or in the new-born until the 
upper margin of the tympanic membrane becomes visible. While 
the speculum is held in this position with the left hand, it is arranged 
with the right so that all or some parts of the tympanic membrane 
may be inspected. The instruments necessary for examination are also 
handled by the right hand. 

2. METHODS OF CLEANSING THE EXTERNAL CANAL AND THE 
TYMPANIC CAVITY 

In order to obtain a sufficiently clear otoscopic picture, it is neces- 
sary to remove the normal or pathological contents of the external 
auditory canal and tympanic cavity (cerumen, epidermal crusts, pus, 
blood, etc.), as otherwise free inspection of the tympanic membrane or 
the parts behind it, if perforated, is interfered with. An angularly 
flexed button-probe serves for examining these masses, which can be 

55 



56 THE DISEASES OF CHILDREN 

removed by small forceps. It is advisable to have two sizes of ear- 
pincettes in readiness which are carefully grooved at the ends (Politzer's 
ear-pincettes). The pus is removed with cotton tips, which have been 
sterilized in sterilizers or by singeing over a flame. At the first examina- 
tion, irrigation with a syringe is preferable to the removal of pus with a 
cotton tip. We are using a sterilizable syringe which can be taken apart, 
holding from 150-200 c.c. It is fitted with a number of cannulas of dif- 
ferent sizes. In syringing the ear, the external meatus is drawn up and 
back, as is done in the otoscopic examination, and the cannula is gradu- 
ally inserted from behind and upward for about 5 mm. In order to 
widen the auditory duct, the mouth should be held wide open. Weak 
antiseptic solutions (2 per cent, boric or salicylic acid, or sterilized 
water) at a temperature of 100°-104° F. are used for irrigation. Sub- 
limate solutions are not permissible in children. 

To cleanse the middle-ear spaces, we are using Politzer's glass 
cannulas. These are provided with a rubber tube and bulb, and by 
aspiration or compression a liquid instilled into the auditory duct and 
tympanic cavity (5 per cent, peroxide, alcohol, etc.) can be moved to 
and fro. The cleansing process should be commenced with aspiration, 
introducing the cannula with bulb compressed. The irrigation fluid 
generally used is peroxide 5.0, aq. dest. 30.0. 

The cleansing process may be extended further by the use of Hart- 
mann's attic cannula. Generally speaking, I prefer metal cannulas 
which can be sterilized by boiling, but in the case of infants and children 
it may sometimes be advantageous to use hard rubber or flexible attic 
cannulas, made of soft red rubber or silk rubber. The latter are gradually 
inserted under the guidance of the speculum down to the place it is 
intended to irrigate, and it is advisable to leave the manipulation of the 
bulb, containing the irrigation fluid, to an assistant. Syringing or irri- 
gating the ear for diagnostic purposes may be combined with testing 
the labyrinth for caloric excitability. 

3. NORMAL OTOSCOPIC PICTURE OF THE EXTERNAL AUDITORY CANAL AND 
TYMPANIC MEMBRANE. OTOSCOPY OF THE TYMPANIC CAVITY 

The posterior end of the exterior auditory canal is sharply demar- 
cated in the otoscopic picture against the tympanic membrane by an 
angle and by the color, the canal having the normal color of the skin, 
while the tympanic membrane is tinged gray or grayish-blue (pearl- 
gray). 

In the normal otoscopic picture (Figs. 24, 47) the entire tympanic 
cavity can be surveyed. Anteriorly from above toward the centre of 
the membrane is the manubrium; the posterior fold of the tympanic 
membrane extends from the short process toward the posterior margin 



EXAMINATION OF THE EXTERNAL AUDITORY CANAL 57 

of the membrane. In normal conditions of the middle-ear spaces it is 
hardly visible in infants. The anterior and posterior folds are usually 
entirely absent. The radial fibres of the tympanic membrane, accu- 
mulated at the umbo, sometimes form the pes anserinus. 

The circular fibrous bundles stretch along the tympanic margin of 
insertion and are usually not visible in the otoscopic examination of 
infants. The light-reflex (light-cone, light-sector, light-spot) extends 
from the middle of the tympanic membrane anteriorly and inferiorly, 
and is most intense at its central point. 

The division of the tympanic membrane into quadrants and circular 
sections (Fig. 47) will facilitate the description of the pathological find- 
ings. Dividing the membrane into quadrants, the pars tensa comprises 
the anterior, superior and posterosuperior, anterosuperior, and postero- 
inferior quadrants. The pars flaccida 
(Shrapnell's membrane) forms a special, 
fifth section. 

The circular sections divide the mem- 
brana tensa into a central, medial, and 
peripheral (external) part of the tympanic 
membrane. A fourth part is supplied by 
the membrana flaccida. 

According to the position of the tym- 
panic membrane in the Skull, the POS- Topographical division of the tympanic 

membrane. 1. Division into quadrants: 

terosuperior quadrant is nearest the eye ?■ posterosuperior quadrant; 6, postero- 

„ , . 1 i • l inferior quadrant; c, anterosuperior quad- 

OI tile examiner, and thlS part IS alSO nor- rant; d, anteroinferior quadrant; e, mem- 

11 i , l ,1 , i brana flaccida. 2. Circular division: a', 

mally larger than the OtherS. central part of the tympanic membrane; 

The gray or grayish-blue tint of the J; SStt;« 
tympanic membrane is much less due to b p ™ e: m e' m b™e. rana flaccida ° f the tym " 
the color of the membrane itself than to 

the law of turbid media seen through the air enclosed in the tympanic 
cavity behind the membrane. 

The parts of the tympanic cavity or its contents which are closest 
to the membrane are, in many cases, visible through the membrane like 
shadows. These parts are (a) the long crus of the incus, (b) the promon- 
tory, (c) the recess of the cochlear window. 

If other parts of the tympanic contents become transparent, such 
as the stapes, chorda tympani, folds of the malleus, etc., it is a sign of 
pathologically increased translucency of the tympanic membrane due to 
atrophy. 

If the auditory canal markedly kinks downward, it may be impos- 
sible with the ordinary speculum to survey the entire extent of the 
antero-inferior quadrant. This would necessitate the application of a 
specially thin speculum which would freely expose the inferior quadrant. 




58 THE DISEASES OF CHILDREN 

Otherwise the width of the speculum should be closely adapted to the 
dimensions of the external auditory canal. If the speculum is too narrow, 
it will not be in contact with the walls of the canal, and an inexperienced 
operator may find it difficult, if not impossible, to localize the tympanic 
membrane. If it is too large, the movable integument of the mem- 
branous auditory canal will be pushed forward in folds, which would 
considerably interfere with the distinctness of the picture. 

If the tympanic membrane is completely absent, it is possible to 
survey the greater part of the internal wall of the cavity, the hypotym- 
panum. the mesotympanum, a considerable part of the contents of the 
cavity, and part of the walls of the attic and antrum. In this way it 
may be possible to investigate otoscopically the entire middle-ear spaces 
down to the tympanic orifice of the tube. In small defects of the tym- 
panic membrane, examination of the perforated fundus with the probe 
and irrigation of the middle ear may directly or indirectly supply infor- 
mation on the condition of the middle-ear spaces. Excellent accessory 
instruments are the attic speculum (Urbantschitsch) and specula with 
a magnifying glass. Hegener has devised an instrument with which it 
is possible to examine the tympanic membrane with the binocular 
stereoscope. 

The electric otoscope, now on the market, offers numerous advan- 
tages, including ease of manipulation, uniform illumination and, by means 
of the rotating lens, considerable magnification of the field. 

The best of these instruments has a bulb attached so that the tym- 
panic membrane may be moved, or, if the membrane be perforated, secre- 
tion may be aspirated through the opening. 



IV. METHODS OF EXAMINING THE MIDDLE EAR 

i. EXAMINATION OF MOBILITY OF THE TYMPANIC MEMBRANE AND OF THE 
CONTENTS OF TYMPANIC CAVITY 

The mobility of the tympanic membrane and the chain of auricular 
ossicles is tested by means of Siegle's otoscope. A tube, about 3 cm. 
long and 1.5-2 cm. in diameter, is attached to an ear-speculum and 
closed at the other end by a glass plate at an inclination of 45° ; laterally 
an air-tight connection is made with a tube carrying a bulb. Inspection 
of the tympanic membrane, while the bulb is being operated, renders 
it possible to decide whether the tympanic membrane has normal, 
exaggerated, or diminished mobility. Atrophied places bulge out upon 
aspiration, while adherent parts remain immovable and thickened parts 
show slight mobility. If the membrane is perforated, the fluid contents 
of the cavity (serum, pus) may be aspirated through Siegle's instrument 
into the auditory canal and evacuated. Before inserting the tube, it 
is advisable to heat the glass plate slightly over a non-smoking flame so as 
to ensure its continuous clearness. 

2. THE VALSALVA TEST. 

Ii the nares are compressed, with mouth closed, a jerky expiratory 
effort will condense the air in the nasopharyngeal space, and, as the 
condensed air penetrates into the middle ear through the passively 
opened Eustachian tube, the tympanic membrane will outwardly pro- 
trude to its maximal extent. In the otoscopic picture the manubrium 
is seen vertically downward and the posterosuperior quadrant appears 
still larger. The outward displacement of the tympanic membrane is 
felt by the patient as a jerk in the aural region or as a subjective noise 
(crackling). The auscultation tube (otoscope) will serve to establish 
this noise objectively. 

. If the Eustachian tube is occluded from acute or chronic swelling 
of the mucous membrane, spasms or tubal musculature, or strictures, 
or if the walls of the tube are interagglutinated by mucous exudates, 
the Valsalva test will be negative, which means that the expiratory 
pressure is not sufficient to open the tube. In that case it will be neces- 
sary to establish the kind and degree of tubal affection by other physical 
methods. 

The Valsalva test is very important for the demonstration of per- 
forations of the tympanic membrane, especially in cases of traumatic 
rupture, the air escaping outwardly through the perforation after passing 
the tube and tympanic cavity. The noise is established by auscultation. 

59 



60 THE DISEASES OF CHILDREN 

The tone level of the noise depends upon the size of the rupture. In 
large gaps there is a deep, bellowing noise, and the smaller the rupture 
and the more it inclines to the shape of a fissure, the more will the sound 
approach to a high whistling noise. Crepitant rales point to accumula- 
tion of secretion in the middle-ear space. According to Kugel's sugges- 
tion, the air escaping through the rupture in the Valsalva test may be 
conducted through water and demonstrated by the ascending air bubbles. 

In perforation of the tympanic membrane, the Valsalva test will 
be positive only if the tube is quite permeable. 

Patients suffering from catarrh of the middle ear usually come to 
recognize the Valsalva test by accident when blowing the nose. At first 
they feel considerable improvement, which will lead them to repeat the 
process frequently. As a rule, they soon acquire considerable aptitude 
in carrying out the experiment, and are able to exercise the expiratory 
pressure necessary for the opening of the tube in a manner almost im- 
perceptible to others. The unavoidable consequence of unlimited 
repetition of this procedure invariably leads to atrophy of the tympanic 
membrane (Politzer). 

3. POLITZER'S METHOD (AIR DOUCHE, INSUFFLATION AFTER POLITZER) 

The patient holds a swallow of water in his mouth. A small rubber 
tube, attached to a bulb, is inserted into the proximal nostril. The 
right hand holds the bulb, the left compresses the nostrils tightly over 
the tube. While the patient performs the act of deglutition, and at the 
moment the larynx ascends and the velum palati closes the oesophagus 
downward, the air is expressed into the nasopharyngeal space. The 
overpressure hereby produced in the latter space causes the Eustachian 
tube to open and allows the air to flood the middle-ear spaces. 

It is usually impossible to make young children hold the water in 
their mouths or to swallow instantly on command. As a substitute 
they may be ordered to pronounce a word ending with a guttural (such 
as chuck, clock). In other cases, a sipping inspiration may bring about 
a successful result. In infants it is best to wait for the commencing 
expiration in crying, during which it is possible to carry out successfully 
the insufflation. 

If it is intended to give a full air douche, the bulb is compressed 
in powerful jerks with the entire hand; a less powerful effect is obtained 
by compressing the bulb with the flat fingers or a few fingers only. It is 
advisable to have children blow their noses before commencing proceed- 
ings. If the permeability of both tubes is normal, the air douche will 
affect both ears simultaneously. If there is considerable resistance from 
occlusion, Politzer's method may be unsuccessful, so that the air con- 
densation obtainable in the nasopharyngeal space is not sufficient to 



METHODS OF EXAMINING THE MIDDLE EAR 61 

overcome the impediment. If the permeability of only one tube is 
affected, the air may escape through the healthy tube, and in order to 
prevent exaggerated bulging out of the tympanic membrane on that side, 
the auditory meatus is firmly closed with a moistened finger. 

The air douche is carried out three or four times at one sitting 
through the right and left nostrils alternately, so as not to injure the 
sensitive integument of the nares and the mucous membrane of the 
nasal septum. Should there be any fissures at the nares, the rubber tube 
should be greased with borovaseline before insertion. 

Politzer's method of insufflation is exceedingly valuable for both 
diagnostic and therapeutic purposes. Of diagnostic importance are the 
improvement in auditory acuity and the changes occurring in the oto- 
scopic picture of the tympanic membrane. The penetration of the air 
into the tympanic cavity is established by auscultation, the operator 
connecting his ear with that of the patient by the otoscope. The success 
of an insufflation is also indicated by murmurs, caused by the vibra- 
tions of the velum palati. Sometimes it is impossible to avoid some of 
the injected air passing into the stomach through the oesophagus when 
the occlusion is removed, but this will cause no inconvenience and the 
air will escape again in a few minutes. Atrophied portions of the tym- 
panic membrane or cicatrices may be torn if the air is injected with undue 
force. If the tympanic membrane is perforated, there will be a charac- 
teristic noise which is audible in Politzer's method by auscultation. If the 
Eustachian tube is of large diameter and the defect of the tympanic 
membrane considerable, the escape of air is sometimes directly felt by 
the examiner through the otoscope. Up to the time of puberty, Polit- 
zer's method represents the only reliable examination of the middle ear 
and is, besides, of considerable therapeutic value. 

4. CATHETERIZATION 

The catheter cannot be used in children until they are from 10 to 
14 years old. It is especially indicated in chronic middle-ear affections 
in which air douches are attended with negative results owing to patho- 
logical obstacles in the tube. The narrowness of the lower nasal entrance 
at an earlier age and the slight extension of the nasopharyngeal space 
are unfavorable to the introduction of a catheter. Its use in older chil- 
dren may become necessary in defects of the hard palate or in paralysis 
of the velum palati. 

The ear-catheter is introduced into the tubal aperture through the 
lower nasal canal. An elastic, well-polished, smooth hard rubber 
catheter (Politzer) with an oval aperture is preferable to one made of 
German silver. Of course, the latter can be sterilized by boiling, but 
the hard rubber catheters can also be reliably sterilized in a sublimate 



62 THE DISEASES OF CHILDREN 

solution and be kept thoroughly clean by rinsing with sterilized water. 
They are preserved dry. 

The use of the catheter should be preceded by a rhinoscopic exami- 
nation. Should the latter reveal any constricting changes in the nose, 
the catheter is introduced into the nostril under the guidance of the 
reflector and the nasal speculum. The operator connects his ear with 
that of the patient through the otoscope. 

As soon as the front end of the catheter has passed the posterior 
border of the hard palate, the problem is to direct the downward aper- 
ture of the catheter into the opening of the pharyngeal tube. The most 
convenient way to do so is to describe a quarter screw-like turn, back- 
ward, outward, and upward. Other topographical methods to facilitate 
the search for the tubal opening or ridge are the following : 

(a) The catheter is advanced to the posterior wall and introduced 
into Rosenmuller's fossa by turning the beak outward by 90°; with- 
drawing the catheter makes it jump over the tubal ridge into the opening. 
Both operator and patient distinctly feel the catheter as it elastically 
glides over the tubal ridge. 

(6) The catheter is inserted through the lower nasal canal in the 
usual way and advanced to the posterior faucial wall. The beak is then 
turned toward the opposite side until it is in a horizontal position, and 
withdrawn to the posterior margin of the nasal septum. From this 
position the beak is turned by 180° downward, where it will find the 
tubal ostium. 

Both methods are unpleasant for the patient; contact with the 
sensitive faucial mucous membrane, the velum palati, and the posterior 
margin of the nasal septum may cause nausea, retching, and even 
positive vomiting. 

If the nasopharyngeal mucosa is inflamed and swollen, the catheter, 
even if ever so carefully handled, may cause injury to the mucous mem- 
brane with subsequent hemorrhage. This is always a very unpleasant 
incident, for, although the hemorrhage is not severe, it may last for 
hours. Disagreeable and long-lasting hemorrhages may also occur in 
the lower nasal canal from injuries to the small vessels of the septum by 
careless or rough insertion of the catheter. 

When the catheter has reached the tubal ostium, the beak is turned 
upward, so that its curvature may assume the direction of the tubal 
axis. This is accomplished by turning the ring of the catheter ("fly") 
upward toward the lateral angle of the canthus. The catheter is now 
firmly held at the nostril by the first and second fingers, the little finger 
finding support against the forehead of the patient. The operator next 
connects bulb and catheter with his free hand, gently and carefully 
compressing the bulb. Powerful insufflation may be made only after 



METHODS OF EXAMINING THE MIDDLE EAR 63 

the characteristic auscultatory noise has convinced the operator that the 
beak is correctly situated in the tubal orifice. 

If the catheter is in a wrong position or if there is an injury to the 
mucous membrane, incautious insufflation may lead to acute emphysema 
of the nasopharyngeal mucosa or of the entire facial epidermis. Such 
an emphysema, however, does not signify any danger, and will usually 
disappear after a few hours or at the most in a few days, when the air 
has been resorbed. Still, traumatic emphysema is less a sign of inexper- 
ience than of careless and even rough handling of the catheter. 

Catheterizing is done with the patient in a sitting posture. If the 
operator prefers the erect position, he should carefully avoid bending 
his body forward or exercising any unnecessary pressure on the instru- 
ment, as it would give the patient unpleasant and painful sensations at 
the tubal orifice in the fauces. The catheter should glide along the base 
of the nose during insertion. If the nasal half pertaining to the ear to be 
examined should not be permeable, catheterization may be done through 
the other half or through the mouth with a catheter of greater curvature. 
It would be far preferable, however, to desist from the process altogether 
for the time being, and remove the nasal obstruction by operation, 
especially as this is usually the cause of the aural affection. 

Insufflation may be carried out with a simple rubber bulb, a duplex 
bulb, a compression pump, or bellows. 

In marked stricture of the Eustachian tube, bougies of whalebone, 
celluloid, gold or silver may be used. A special Eustachian catheter is 
introduced in the usual way, inflation attempted, then the bougie, which 
must be passed with considerable care, otherwise the mucous membrane 
may be lacerated. Recently electric bougies have been used. Obviously, 
this procedure demands knowledge and skill. 



V. THE FUNCTIONAL HEARING TEST 

The function of the auditory organ is to perceive both sounds 
and noises. Formerly sounds and noises were considered separate 
perceptions, but stroboscopic examination has demonstrated the fact 
that all kinds of acoustic productions belong together. According to 
former notions, the cochlea could only perceive sounds, while the rest 
of the labyrinth (semicircular canals and vestibule) perceived noises; 
but the fact is now established that the last-named parts of the aural 
apparatus have nothing to do with the act of hearing, and that acoustic 
manifestations of whatever nature are perceived by the cochlea alone. 
The stimulation excited in the cochlea is transmitted to the cerebral 
cortex by the auditory nerves and their central tracts. 

To make an exact hearing test, it is absolutely necessary for the 
patient to be perfectly alert and to exert a marked degree of concentra- 
tion and attention. It is not sufficient for the patient to react more or 
less automatically to sound stimulation; he is expected to make definite 
statements, as for instance where he has heard a certain sound, or to 
indicate by signs at what moment certain sounds of the tuning-fork 
cease to be audible; he has to differentiate sounds and to state his per- 
ception as to their quality and timbre. 

In the test for bone conduction, patients should be requested to 
separate psychically the sensation of vibrations of the tuning-fork from 
the perception of the sound and to pay exclusive attention to the latter. 

I. DETERMINATION OF AUDITORY ACUITY IN RELATION TO SPEECH ; 

THE ACOUMETER 

If the auditory acuity is to be tested by having certain sounds 
repeated, it is essential that the patient should not merely hear the 
words, but understand them and be intelligent enough to repeat them. 

It is unavoidable, therefore, that hearing tests embrace to a large 
extent intellectual tests, and for this reason exact and comprehensive 
hearing tests in infancy are surrounded with difficulties. The age limit 
coincides about with the school age, but prolonged tests should not be 
made on children under 10 years of age, since their power of concentra- 
tion is too rapidly exhausted and reliable statements of perceptions 
may not be expected. Even in adults, especially in nervous persons, 
a few minutes' interval must frequently be allowed in order to exclude 
the possibility of inaccurate statements due to fatigue. 

In pathological examinations, the functional hearing test follows 
after the otoscopic examination. The external auditory canal should 

64 



THE FUNCTIONAL HEARING TEST 65 

be cleansed and any accidental obstacles to sound conduction, such as 
cerumen, epidermal parts, scales, pus, etc., removed, so that the func- 
tional test may give a clear picture of the capacity of the organ. 

The functional test is best divided into one for auditory acuity 
(distance) for spoken sounds, and one for noises. 

The production of spoken sounds is dependent upon: (1) articula- 
tion (function of the vocal muscles), (2) condition of the vocal cords, 
(3) expiratory pressure under which the air escapes from the lungs while 
speaking. 

Articulation is the same in all kinds of speech. The ordinary tone 
of conversation is obtained by articulation with tension of the vocal 
cords in ordinary expiration. Very loud conversation requires forced 
expiration. Articulation with relaxed vocal cords produces whispering. 
If this relaxation is associated with the maximal pressure of expiration, 
the result will be accentuated whispering. Typical whispering is pro- 
duced with the aid of residual air which is simply allowed to pass out 
from the lungs. Residual air is that quantity of air which remains be- 
hind in the lungs after ordinary expiration. 

The normal hearing distance for exaggerated conversational sounds 
in the open is about 60 yards ; for ordinary conversational language and 
under average conditions of conduction in closed rooms, 40-50 yards; 
for accentuated whispering, 25-30 yards; for typical whispering, 20-25 
yards. These figures refer to absolutely normal organs, and will undergo 
a considerable reduction when the organs are even slightly pathologic. 

Importance of the Hearing Test by Speech. — The importance of 
the hearing test by speech, especially by conversation, requires no demon- 
stration. If a person complains of defective hearing, he means in the 
majority of cases that he cannot catch the spoken sound, and it is clear 
therefore that, aside from other tests, the auditory acuity for speech 
should be especially determined. Besides, whatever improvement in 
the auditory faculty is achieved by treatment must be tested by the 
perception of the spoken sound. 

The exaggerated conversational tone is only used where the aural 
affection has so far advanced as to render the perception of ordinary 
conversation impossible. It serves to find out whether patients can still 
understand words or only perceive sounds. The hearing distance for 
exaggerated conversation need not be ascertained, since overloud con- 
versation at a distance of one-half yard only occurs in cases where ordi- 
nary conversation is not understood. 

It is the latter which is of fundamental importance for the hearing 
test. It represents that kind of speech which is almost exclusively 
practised in ordinary life, and should always be taken into consideration 
whenever the hearing capacity of a patient in his intercourse with others 

Vol. VI— 5 



66 THE DISEASES OF CHILDREN 

is to be established. The hearing distance for ordinary conversation, 
however, is so great that in a clinical room of average size the limitation 
of slightly reduced capacity cannot be tested. In these cases typical 
whispering is resorted to, and from the results conclusions are drawn as 
to the patient's ability to understand ordinary conversation. Accentu- 
ated whispering is of less importance in clinical examinations, since it 
may be heard at a comparatively great distance and is unsuited to de- 
termine the limitation of hearing in slight affections even in comparatively 
large clinical rooms (5X6 yards). If, however, the hearing distance 
is to be established for definite performances, such as are prescribed by 
law, for instance, accentuated whispering is the only test to be applied, 
because here individual differences of speech on the part of various 
examiners as to distinctness and quality of sound are least pronounced. 

TEST ARRANGEMENT FOR SPEECH 

Binaural Test. — The patient is placed opposite the physician, with 
his eyes cast down. Correct answers to simple questions, adapted to his 
range of understanding, will establish the hearing distance. This test 
yields only an approximate, but very characteristic, picture of the hear- 
ing ability of the patient, and it is advisable always to use the binaural 
test at the first examination as well as at the close of the treatment. 

As a matter of course, certain precautions should be observed, to which 
further reference will be made in the description of the monaural test. 

Monaural Test. — In the monaural test the hearing capacity of 
the right and the left ear is established separately by excluding the 
function of one ear so far as possible. But it may at once be stated that 
a complete functional exclusion of one ear is impossible, thus rendering 
an ideal monaural test illusory. It is impossible to prevent a certain 
quantity of sound waves reaching the other ear by conduction of the 
cranial bones, a point which will be further discussed when treating of 
unilateral deafness. The patient closes the meatus of the ear not to be 
examined by inserting a moistened finger tip into the canal, care being 
taken not to press the tragus against the orifice of the canal. In exami- 
nation of young children this should be attended to by a third person. 
The other hand is held before the patient's eyes so that he may not be 
able to read off or guess the words from the examiner's lips. 

Method. — The patient turns the ear to be examined toward the 
physician. This is the "direct method," and the established distance 
is called the auditory distance by direct method. When the closed ear 
is turned toward the physician, we speak of the "half-direct method," 
and when the physician stands with his back toward the closed ear, it 
constitutes the "indirect method." Other expressions are direct, half- 
direct, and indirect conversation. 



THE FUNCTIONAL HEARING TEST 67 

Computation. — In order to find the distance for direct conver- 
sation, the figure obtained for half-direct conversation is increased 
by one-third, that obtained by the indirect method by two-thirds. 
For instance, a hearing distance of 6 yards in half-direct conversa- 
tion is equal to 8 yards of direct conversation, or 6 yards of indirect 
is equal to 10 yards of direct conversation. In this way it is pos- 
sible to find out the hearing acuity of a person up to 10 yards 
in a room only 6 yards long, or up to 15 yards in a room 9 yards 
long. If the patient is able to repeat correctly and promptly the 
required words at the greatest distance attainable in a given room, the 
findings are marked by +. Thus C + 10 would mean that the patient 
has correctly and promptly repeated ordinary "Conversation" at a 
distance of 10 yards. 

Field of Combination. Medial Hearing Distance. — The hearing 
distance for conversational language can only be ascertained as "medial 
distance." A patient may faultlessly and promptly repeat all test words 
at a distance of 6 yards, while at a distance of 73^-8 yards he may not be 
able to repeat a single word. On the other hand, at a distance of 6-7 J4 
yards it is found that he can still correctly repeat easy, polysyllabic 
words, words containing high vowels and the consonants "r" and "s" 
and adapted to his range of intellect and thought. His hearing at this 
distance is indistinct ; he takes in only the "word-skeleton" and combines 
with surprising rapidity some word from the sounds he has caught. 
Sometimes this is the correct word, but the evidence of its being the 
result of combination is furnished by the fact that he does not repeat the 
word instantly, but only after a few seconds' meditation. In most cases, 
however, the resultant word, though similar in sound, is totally differ- 
ent in meaning, as, for instance, "paper" for "vapor," "window" for 
"widow," etc. 

Correct combination is more than usually easy in the repetition of 
numerals, and it is therefore inadvisable to use numerals exclusively 
for test purposes, as is recommended by some authors. 

The distance at which a patient hears only the word-skeleton and 
constructs the supposedly correct word by combination is called the 
combination distance or field. Its extent chiefly depends upon the 
patient's age and temperament. Children under 10 years of age and 
phlegmatic or torpid individuals but rarely exhibit any combination 
field. In these cases the positive hearing distance immediately borders 
upon the negative field, in which not a single word can be repeated. 
Active individuals combine to a much greater extent than the phleg- 
matic; furthermore, patients with a chronic aural affection resort to 
combination more frequently than those suffering from an acute affec- 
tion, for the simple reason that the former are constantly compelled in 



68 THE DISEASES OF CHILDREN 

ordinary intercourse to resort to it and have thus acquired greater 
practice. In this connection it is a surprising fact that the gift of 
combination is entirely independent of the degree of intelligence, quite 
uneducated individuals sometimes furnishing a very interesting and 
varied field of combination. 

How to Test by Speech. — In establishing the medial hearing dis- 
tance, care should be taken to exclude all sources of error in order to 
expedite the test. The words should be so spoken that the patient may 
distinctly hear and understand them. Wolf, of Frankfort, was the first 
to divide the German language into word groups t)f varying audibility. 
Words of a high degree of audibility are those containing several sylla- 
bles and high vowels; those of medial audibility are polysyllables with 
high and dull vowels; and to this group belong the numerals. Words 
of bad audibility are those of one or two syllables containing dull vowels 
and labial sounds. 

The audibility of a word is increased by pronouncing it slowly and 
distinctly; this is facilitated by preceding each substantive by the arti- 
cle and by observing a pause of about five seconds between every two 
words. Furthermore, patients are able to hear and understand words 
better which have been selected according to their age, education, 
and range of thoughts, and it is advisable to take these points into 
consideration not only to expedite the test, but also to avoid 
blunders. If the test is wrongly conducted, the result will repre- 
sent the minimal distance, which is clinically quite uninteresting and 
diagnostically of no value. 

These points are of still greater importance if the object of the test 
is not simply to ascertain the hearing distance, but to demonstrate any 
improvement after treatment. In the latter case it is important not to 
use words with which the patient has become familiar from previous 
examinations. 

It is quite possible that at the first examination the established 
figures are low from the fact that the patient is unfamiliar with the 
method of testing and becomes confused or excited. It is always ad- 
visable, therefore, to follow up the first test by a second one after a lapse 
of time, when useful figures will be obtained. 

The various points above referred to are also brought out in 
the history of those difficult of hearing; thus, patients understand 
the language of those they know, especially of relatives, better than 
that of strangers. The language of women, being more modu- 
lated, is better perceived than that of men. Those afflicted with 
hard hearing may still understand the words of a song in a theatre, 
but be unable to follow the spoken text, musical sounds being louder 
and more voluminous. 



THE FUNCTIONAL HEARING TEST 69 

Hearing Test by Whispering. — The combination field for whispers 
is usually small (1-13^ feet). The presence of a combination field ex- 
cludes possibility of simulation (see Simulation) . 

Hearing Distance for Politzer's Acoumeter. — It is useful to sup- 
plement the hearing test for conversational and whispered language by 
Politzer's acoumeter. This handy and excellent instrument consists 
of a hard rubber column with a steel cylinder attached, and a small 
steel lever above the cylinder. The lever may be dropped upon the 
cylinder at a uniform distance, producing a noise not dissimilar to the 
ticking of a clock and audible with normal ears at a distance of 15 yards. 
The result is recorded in a fraction, the numerator of which represents 
the established distance and the denominator the normal distance (15 
yards). The test is commenced in immediate proximity to the ear, 
with the patient's eyes covered, the distance being gradually increased 
until the hearing limit has been reached, and beyond. These figures 
are controlled on the return journey. 

II. TUNING-FORK TEST 

Testing the ear for the perception of musical sounds is an important 
link in the system of functional tests. 

The tuning-fork should be large, with a handle of at least 8 cm. 
Handle and prongs should be made of one piece and not be soldered. 
Nickel-plated forks cannot be recommended, the duration of their 
vibrations being impaired. For clinical purposes an instrument should 
be selected free from overtone and with long-lasting vibrations, so that 
the length of perception may be conveniently compared with that of a 
normal ear. If the vibrations are rapidly arrested, there may not be 
time enough to establish precisely the difference of perception between 
the normal and the pathologic ear. Most of the overtones can be elimi- 
nated by weighting the end of the prongs, and in clinical language 
forks free from overtones are weighted forks. Speaking from a purely 
technical point of view, there are no forks entirely free from over- 
tones, some of them being always present in the vicinity of the 
ground tone. Exaggerated weighting of the forks lessens the duration 
of their vibrations. 

Tuning-forks of sufficient size and adequately weighted can be 
used to test musical scales : the nearer the weights are brought to the base 
of the fork, the higher will be the sound. 

Intensity of Sound. — The intensity of the sound of the tuning-fork 
is indicated by the distance at which the sound is still perceptible by 
the normal ear. The sound of low forks, even if firmly struck, is not 
very intense, while those of a high pitch, even if softly struck, are audible 
at a considerable distance. 



70 THE DISEASES OF CHILDREN 

Compass of Sound. — The human ear is capable of perceiving from 
12 to about 40,000 (double) sound vibrations. For clinical purposes a 
fork is used having about 16 vibrations for the lower sound limit (C2) 
and 4224 vibrations (c 5 ) for the upper limit. 

Clinical Test Methods. — We distinguish between (A) general, (B) 
qualitative, and (C) quantitative tuning-fork tests. 

A. GENERAL TUNING-FORK TESTS 

A long, weighted c 1 - or a ^tuning-fork, or an unweighted a^fork, 
of pure sound, is used for the tests. The kind of fork used should be 
recorded, as a guide for possible control tests. 

(1) Weber's Test. — The sounding fork is placed against the vertex 
of the patient, who will have to state where he hears the sound. If 
both ears are normal or equally affected, the sound will be heard either 
in both ears, in the head, at the point of contact, or in space. In uni- 
lateral aural affections there will be lateralization of the sound to one 
side. If the sound-conducting apparatus (of the external and middle 
ear) is diseased, the sound will be perceived on the pathological side, — 
i.e., lateralized to that side. If the sound-perceiving apparatus (of the 
internal ear: labyrinth, auditory nerve) is diseased, lateralization ensues 
toward the healthy or less affected side. If lateralization is not suffi- 
ciently distinct, the patient will be unable to make a definite statement. 
In this case, lateralization can be intensified by using a lower-pitched 
fork or by selecting another point of contact in the cranial medial line 
(forehead, teeth, nape of the neck, occiput). 

The test is explained as follows: Lateralization to the healthy or 
less affected side is easily intelligible in cases of a diseased perceiving 
apparatus. If the auditory nerve on one side is intact, that of the other 
diseased (atrophied, for instance), and the labyrinth degenerated, the 
sound of the fork will, as a matter of course, be lateralized to the normal 
or less affected side. Lateralization in cases of an affected conducting 
apparatus may be theoretically explained as follows: The sound of the 
fork on the vertex is perceived through the cranio-tympanic and cranio- 
labyrinthine conduction. An affection of the conducting apparatus 
will not affect the cranio-labyrinthine conduction. On the other hand, 
the sound waves reaching the bone by the route of the cranio-tympanic 
conduction are normally changed into air waves in the middle ear, and 
it is only after this transmutation has taken place that they will reach 
Corti's organ. This transmutation of waves in the middle ear causes 
some loss of intensity, and, besides, a certain quantity of sound waves 
passes out through the external auditory meatus. This fact is easily 
demonstrable by the otoscope: if the patient's ear is connected with that 
of the operator, the latter is able to hear the sound of the fork. But if 



THE FUNCTIONAL HEARING TEST 71 

there is an obstacle interfering with sound-conduction in the external 
canal or middle ear, the normal loss in intensity is either completely 
eliminated or considerably reduced, so that the fork will be heard more 
intensely than in normal conditions. The objective prolongation of the 
cranial conduction in affections of the sound-conducting apparatus fol- 
lows from the same considerations. 

Weber's test is of clinical value only in so far as lateralization un- 
questionably indicates an aural affection, as in bilateral normal con- 
ditions it cannot possibly occur. It is of considerably less value for 
differentiating between the affections of the sound-conductors and those 
of the sound-perceivers. In affections which have both otoscopically 
and functionally been proved to be such of the sound-conductors, the 
labyrinth being perfectly intact, some patients will lateralize to the 
healthy side, being under the impression that an otherwise inferior, 
affected ear would not be able to perceive the sound of the fork better 
than the good ear. Thus, they consider it but natural that the healthy 
ear should perceive the sound in Weber's test better than the affected 
one. These patients are not sufficiently mature to answer questions 
correctly. Again, in positively demonstrated affections of complete 
destruction of the labyrinth, the sound coming from the fork may be 
lateralized to the affected side, although the reverse would have been 
expected. The explanation is that, although the affected ear no longer 
exercises any physiological function, especially after the radical opera- 
tion, it yet acts as a powerful mechanical resonator, and the sound is 
thus erroneously taken to come from the resonator. This is a regular 
occurrence in experiments upon the normal ear with artificial occlusion 
of the external meatus. 

(2) Schwabach's Test. — The vibrating fork is placed upon the 
middle of the forehead, the patient being requested to state whether or 
not he hears the sound of the fork. To obviate fatigue or suggestion, 
the fork is removed and replaced at short intervals, the patient having 
to answer the question on each occasion. If there is any doubt as to 
whether the patient can distinguish between the mere vibrations and 
the sound they produce, the fork is placed against the wrist or patella: 
if the patient really perceived the sound from the middle of the forehead, 
he will now state that he can only perceive vibration at the wrist or 
patella; if, on the other hand, he had only perceived vibrations at the 
forehead and erroneously taken them for sounds, he will commit the 
same mistake with the fork against the wrist or patella. 

The duration of sound-perception is divided into normal, shortened, 
and lengthened, and their various degrees can be best established by 
the Kittlitz tuning-fork, as recommended by Bloch, or by the same 
instrument as modified by Bernd, or by Gradenigo's fork. 



72 THE DISEASES OF CHILDREN 

In affections of the sound-conductors, the cranial conduction is 
prolonged; in those of the middle ear it is shortened. The degree of 
shortening practically corresponds to the degree of deafness, while the 
degree of prolongation does not correspond to the degree of the affec- 
tion. In acute otitis media it will usually be found greater than in 
chronic cases. The physiologic explanation of Schwabach's test is the 
same as that of Weber's test. 

It is an interesting and fundamental fact in Schwabach's test that 
the affected side has a preponderating influence in the middle of the 
forehead. If, in a unilateral affection, the cranial conduction of that 
side is prolonged, it will also be prolonged from the middle of the fore- 
head, but shortened in unilateral affections of the middle ear. Some 
authors apply Schwabach's test from the mastoid processes instead of 
the forehead, erroneously supposing that the conduction thus found 
represents a picture of the cranial conduction of a particular side, which, 
however, is not the case. For instance, the conduction found at the 
right mastoid will furnish a picture of cranial conduction representing 
the capacity of the right ear to a greater extent and that of the left ear 
to a less extent, but the degree of participation of either ear cannot be 
precisely determined. 

In my opinion it is preferable, therefore, to provide topographically 
equal conditions for both cranial halves by placing the fork in the middle 
of the forehead. 

The duration test in normal individuals sometimes discloses con- 
siderable individual deviations. Abnormal duration, however, can 
only justify the assumption of an aural affection if the other func- 
tional tests, especially the determination of the aural acuity, should 
confirm it. 

Schwabach's test is a very valuable diagnostic aid if practised with 
the necessary precaution. 

(3) Rinne's Test. — This test results from a comparison of the 
duration of the cranial and air conductions of the same side. If the 
sound of the fork is no longer perceived at the mastoid, a normal ear 
can still perceive it for some time through air conduction (Figs. 48, 1), 
the duration being normally longer through air than through cranial 
conduction. Rinne's test is called positive if the air conduction pre- 
ponderates over cranial conduction, and negative in the reverse case. 
In aural affections the air conduction is shortened, and the fact of its 
being shortened indicates the presence of an aural affection, whatever 
its origin may be. Cranial conduction, however, varies, and, as has been 
shown in the description of the Weber and Schwabach tests, is pro- 
longed in affections of the sound-conductors and shortened in those of 
the sound-perceivers, as compared to normal. 



THE FUNCTIONAL HEARING TEST 



73 



This leads to the following divisions of Rinne's test (Fig. 48, 1-7) : 

1. In the normal ear, Rinne's test is positive with normal duration 
of perception through either cranial or air conduction (Fig. 48, 1). 

2. In affections of the sound-conducting apparatus, Rinne's test is 
negative, with shortened air conduction and prolonged cranial conduc- 
tion (Fig. 48, 2). 

3. In affections of the sound-perceiving apparatus, Rinne's test is 
positive, with shortened cranial and shortened air conduction (Fig. 48, 3) . 

4. In affections of the sound-conducting and sound-perceiving 
apparatus, the Rinne test is negative, with shortened cranial conduction 
(Fig. 48, 4). 

5. In advanced stages of hearing insufficiency, the Rinn6 test is 
always negative (Fig. 48, 5), whether the affection involves the sound- 



1. 



o. 



Fig. 48. 
4. 



K L K L K L K 



N 



V- I 



6. 7. 

K L K L 



Graphic repre3entation of Rinne's test for clinieo-diagnostic purposes. K, crania! conduc- 
tion; L, air conduction. 



perceiving or sound-conducting apparatus, or both. In the most ad- 
vanced stages of progressive insufficiency, air conduction always dimin- 
ishes more rapidly than cranial conduction. In very advanced cases, 
therefore, Rinne's test is of no diagnostic value. 

The test is indifferent, undecided, or simultaneously positive and 
negative : 

6. In light affections of the sound-conductors, in which there is a 
prolongation of the cranial conduction and a slighter shortening of the 
air conduction in such proportion that the same duration results from 
both ways of conduction (Fig. 48, 6). 

7. In many advanced cases of middle-ear affections (Fig. 48, 7). 
Rinne's test is an exceedingly valuable diagnostic aid, provided the 



74 THE DISEASES OF CHILDREN 

precautions resulting from a study of Fig. 48 are observed (comparative 
measurement of the time of perception). 

(4) Politzer's Test. — While the patient holds a swallow of water in 
his mouth, the tuning-fork is held before his nose. The sound will be 
perceived stronger during the act of swallowing if the tube is normal, 
the volume of tone suddenly increasing. The test proves the importance 
of the pharyngo- tympanic air conduction. 

The test is negative in tubal affections. In unilateral affections, 
the sound will only be heard through that tube which opens during the 
act of swallowing. 

Thus, the condition of the Eustachian tube can be rapidly estab- 
lished by this test, which is particularly valuable in cases where other 
methods of tubal examination are not available. 

(5) Gelle's Test. — This test is carried out with a weighted C^-fork 
and a rubber tube provided with an olive nozzle and a rubber bulb. The 
latter has an aperture at the side, which can be closed with the thumb 
(Bloch). The moistened nozzle is fixed air-tight in the auditory meatus 
and the sounding fork placed upon the bulb. On compressing the latter, 
with its lateral aperture closed, the perception of the sound will be con- 
siderably diminished. On liberating the aperture and thus reducing 
the increased pressure to normal, the intensity of the sound increases to 
its former level. 

The following theoretical considerations will explain the test : 
Compression of the bulb serves to raise the air pressure in the area 
of the sound-perceiving apparatus down to the labyrinth, causing the 
mobile parts of the labyrinthine window (plate of stapes, membrane 
of the cochlear window) to protrude into the labyrinthine spaces. 
This leads to an increase of the intralabyrinthine pressure, with 
diminution or arrest of mobility (vibration) of the stapes and the 
membrane of the cochlear window. This condition amounts to an 
artificially produced disease of the labyrinth, in which sounds are 
perceived less clearly than under normal conditions. On restoring 
the original condition by releasing the aperture of the bulb, the 
labyrinth returns to its normal condition, and the sound is perceived 
more strongly. 

The normal result of Gelle's test is called positive. It is negative 
if the mobility of the parts in the area of the labyrinthine window is 
arrested by congenital or acquired changes, — i.e., experimental changes 
of the air pressure will not alter the perception of the sound from the 
fork. In cases of diminished mobility the test is indistinct; sometimes 
it is at first negative but becomes positive on repeated application, 
evidently in consequence of the massage of the ossicles affected by ap- 
plying the test. 



THE FUNCTIONAL HEARING TEST 75 

It is an important fact that, under normal conditions of the osseous 
capsule of the labyrinth, the experimental elevation of the air pressure 
leads only to functional disturbance in the acoustic labyrinth (cochlea), 
while the semicircular canals and vestibule remain unaffected. 

When placing the fork against the mastoid in this test, the cranial 
conduction will be shortened in proportion to the increase in air pressure. 
In Gelle's test the fork may also be placed upon the vertex in cases which 
do not lateralize the sound in Weber's test. At first, the patient lateral- 
izes the sound to the side blocked up by the nozzle, the latter being an 
impediment to sound-conduction. An artificial affection of the laby- 
rinth produced by air compression will cause the sound to be lateralized 
to the other side. 

Gelle's test is exceedingly valuable, furnishing as it does a reliable 
picture of the condition of the labyrinthine window. The negative 
results have come to be considered a special diagnostic sign of otoscle- 
rosis, and sometimes render an early diagnosis of this serious affection 
possible. 

The positive vestibular reaction in Gelle's test is considered to be 
a symptom of fistula (see p. 91). 

B. QUALITATIVE TEST BY TUNING-FORK 

The qualitative test is made by tuning-forks of different pitch or, 
in certain cases mentioned below, by a continuous series of differently 
pitched forks. 

In testing for quality, or timbre, air conduction is availed of. The 
simplest test is made with a weighted deep (C 1 ) and an unweighted 
high (c 4 ) tuning-fork. 

Perception of the deep sound is considerably diminished, or in- 
hibited, by an obstacle to conduction. Shortened perception of a high 
sound points to an affection of the cochlea, which, according to Helm- 
holtz's theory, is situated in the vestibular section reserved for the 
perception of high sounds. This brings us to the following conditions : 

1. If there is an obstacle to conduction, C 1 is negative or consider- 
ably shortened c 4 normal. 

2. If there is an affection of the sound-perceivers in the area of 
the vestibular section of the cochlea (the perceptive place for high 
sounds), C 1 will have normal, c 4 shortened duration. This simple test 
with a deep and a high fork enables us to diagnose any obstacle to con- 
duction. But an affection of the perceiving apparatus can only be 
diagnosed with it if the vestibular part of the cochlea is affected and the 
remaining parts of the cochlea are healthy. Nearly all cochlear affec- 
tions emanating from a middle-ear affection correspond to this relation, 
and the test with the unweighted c 4 -fork is exceedingly valuable in 



76 THE DISEASES OF CHILDREN 

determining whether in otitis media the cochlea is still intact or already 
involved. In the former case, the c 4 -fork will be heard through air 
conduction either at normal time or shortened only a few seconds. 
The first sign showing that otitis media has spread to the labyrinth 
consists in considerably shortened perception of c 4 -fork through air 
conduction. 

This unweighted fork is selected for special reasons: Its pitch is 
high enough to make a diagnosis of the condition of the vestibular part 
of the cochlea, while the duration of its vibrations is still long enough 
to admit of convenient comparison between the time of perception 
of the affected with that of the normal ear and to establish the exact 
degree of shortening in seconds. A good c 4 -fork should vibrate for 
54-60 seconds, while even the best c 5 -fork will not vibrate for more 
than 8-12 seconds, which is not long enough to admit of a convenient 
and exact comparison of the time of perception between a diseased and 
a normal ear. 

It will thus be seen that the forks C 1 and c 4 will not meet the re- 
quirements of all cases. Where they fail, it will be necessary to use a 
system of serially pitched forks. For this purpose the following instru- 
ments have been devised: (1) the serial fork-pipe instrument of Bezold- 
Edelmann, which is provided with resonators; (2) Stern's sound variator; 
(3) the harmonica of Urbantschitsch. 

Bezold-Edelmann's continuous-sound series consists of 10 weighted 
tuning-forks, each of which can be varied in pitch by shifting the weights. 
The totality of the 10 forks contains every sound from C 2 to a 2 . There 
are three pipes for the higher sounds of the scale commencing with a 2 , 
the compass of the large pipe extending from a 2 to a 3 , that of the small 
one from a 3 to a 4 . The compass of the Galton pipe extends from a 4 to 
the highest note limit. 

Recently the monochord has been recommended to determine the 
highest tone limit. It contains four additional unweighted forks, so as 
not. to do without any forks entirely in a pipe system. The vibrations 
of these forks are as follows: g 3 1550, c 4 2069, g 4 3100, c 5 4138. 

In Stern's sound variator an almost imperceptible transition from 
one sound to another may be accomplished by changing the length of 
the pipes. The clinical use of this excellent instrument, however, is 
handicapped by the necessity of using bellows, making it untransportable, 
and also by its cost. 

With the harmonica of Urbantschitsch sounds of uniform strength 
are attainable by attaching pipes of various lengths to a harmonica. 
This instrument is particularly suitable for determining the remaining 
degree of hearing in very advanced cases and for the examination of 
deaf-mutes. 



THE FUNCTIONAL HEARING TEST 77 

The routine use of a continuous series of sounds is not feasible, 
owing to the length of time required for examination, amounting as it 
does to one or two hours. It will, therefore, be reserved for cases in 
which the ordinary methods are not sufficient. In connection with 
these points, the following remarks may be made: 

(1) It has already been pointed out that the relation of "C 1 posi- 
tive and normal, c 4 shortened and negative," only holds good for certain 
forms of affection of the cochlea, particularly for those which have 
remained confined to its vestibular part. If, on the other hand, the 
pathologic changes permeate the cochlea or the auditory nerve in the 
shape of foci, the hearing ability will be suddenly and irregularly im- 
paired or destroyed for certain series of sounds and remain normal for 
others. This results in the so-called acoustic or sound islands (Bezold), 
and it stands to reason that these can only be localized by tests with a 
continuous series of sounds. The diagnosis in many cases of traumatic 
affection of the labyrinth can only be made after a test with one of these 
instruments. So far as forensically important cases are concerned, it 
will therefore be advisable to make a test with a continuous series of 
sounds the basis of functional examination. 

(2) An important part in the symptomatology of subcortical sen- 
sory aphasia is played by word-deafness. Patients thus afflicted at 
first convey the impression of being totally deaf, being entirely unable 
to understand words, so that all conversation has to be carried on in 
writing. Music, however, is perceived by them. In these patients, 
the question of sound-perception can only be determined by the con- 
tinuous acoustic method, and it is only due to these tests that it is known 
to-day that patients with subcortical sensory aphasia may have a good 
and sometimes perfectly normal ear for music. 

(3) The examination of deaf-mute children was originally restricted 
to the quantitative measurement of acoustic remnants. It was on 
Itard's suggestion that deaf-mutism in its wider sense was divided into 
five groups or degrees. These groups comprise all those children whose 
sense of hearing has been impaired to such an extent as to disqualify 
them from following instruction at school. These children, if left to 
themselves, develop their own way of making themselves understood by 
gestures or signs, but articulate language is usually denied them. 

The five groups are the following: (a) total deafness, (6) ability 
to perceive great noises, (c) ability to hear vowel sounds sung with 
a loud voice, (d) ability to hear easy words spoken with a loud voice, 
(e) ability to understand ordinary conversational language at a distance 
of 1-2 m. 

The deaf-mute inmates of an institution comprise a mixture of 
these various degrees. Instruction, and methods of imparting it, must 



78 THE DISEASES OF CHILDREN 

be adapted to average preparatory conditions. If all the children of 
whatever degree of deaf-mutism are brought together in one class, those 
with a partial sense of hearing will learn their lessons better and quicker 
than those totally deaf. The fact is that for groups b and c the quanti- 
tative and qualitative tests are not sufficient to allow of an opinion as to 
their possibilities, and it is highly questionable whether in individual 
cases the acoustic remnants benefit the children in instruction and edu- 
cation or not. (There is no need to emphasize specially the great im- 
portance of useful acoustic remnants in the development of intelligence 
and knowledge in school children. The chief aim in the education of 
deaf-mute children is to impart to them a sound-language and articula- 
tion. The attainment of these objects is powerfully advanced and 
facilitated by the smallest useful remnants of hearing. The methods 
of instruction can avail themselves with the greatest benefit of any such 
remnants that may be preserved (Bezold, Urbantschitsch), and, as an 
immediate consequence of this fact, attention should be centred in a 
system according to which children with useful remnants of hearing are 
placed in a special class. Instruction in such a class may be much more 
rapid than in classes reserved for the totally deaf and those with useless 
remnants.) 

The quantitative tests for groups b and c are not sufficient to estab- 
lish the value of the remaining acoustic remnants; this can only be ac- 
complished by the qualitative .test with Bezold 's continuous series of 
sounds, since stroboscopic examinations of the language have shown 
that a compass from b 1 to g 2 (Bezold) must at least be preserved for 
hearing the spoken language. 

It is evident that only such acoustic remnants can be serviceable 
which lie within that area, and to determine upon the value of these 
remnants the continuous-sound test is indispensable. The test is in 
all cases monaural. The ear not -under examination is firmly plugged 
with cotton saturated with glycerine. It is advisable to commence the 
test with the c^fork, proceeding downward first to the lowest end of 
the series and establishing the lowest sound limit. Only then should 
the upper series be dealt with in the same way, until the upper sound 
limit has been reached. The patient should be carefully watched during 
examination, and, if there should be any fatigue apparent, the exami- 
nation should be interrupted for some time, if necessary for several 
hours. 

This test presupposes the ability on the part of the child to display 
a high degree of attention and concentration, qualifications which are 
only acquired at school. For this reason no test should be made before 
the end of the first school year. In less intelligent children no reliable 
test can be made before the end of the second, third, or fourth year. 



THE FUNCTIONAL HEARING TEST 79 

C. QUANTITATIVE TEST BY THE TUNING-FORK 

i. Measurement of the Difference of Perception. — The object of 
the quantitative test is to establish the difference in time between the 
duration of perception in the affected and a normal ear. Generally 
speaking, any increase in this difference is proportionate to the degree 
of hearing insufficiency present. As a matter of course, none but air 
conduction is of any particular importance for this measurement. 

As soon as the patient indicates by raising his hand that he no 
longer perceives the sound of the fork a stop-watch is set going and the 
moment the sound is no longer heard by a normal ear the watch is 
stopped. This method, however, is very lengthy and applicable only if 
the examiner himself is of normal hearing. 

2. Quantitative Test with the Bezold-Edelmann Graded Sound 
Series. — A comparatively simple and sufficiently exact test can be made 
with Edelmann's tuning-forks, which are of excellent workmanship. 
Every experienced examiner becomes accustomed to a certain intensity 
of stroke, whether the large forks are struck with the palm of the hand, 
with the thumb, or, as is usually done with small forks, with a striker. 
Every examiner can determine for his own instrument the time of per- 
ception, provided, of course, the stroke is always the same. The degree 
of shortened perception in the patient can then be numerically deter- 
mined without difficulty, and the graphic record of the result represents 
"Bezold's acoustic relief." Its working basis for deep and medium forks 
may be formed by the duration of vibrations when the forks are un- 
weighted (Bezold) or when weighted (Fig. 51). 

3. The Gradenigo Forks. — A black triangle, divided into four parts 
by lateral lines, is attached to the weights of a tuning-fork. The fork 
being struck, two gray-tinted triangles become visible to the eye, which 
in the course of the vibrations cover each other at a progressive rate. 
The time required from the partial covering of the triangles at a definite 
division line to the complete stand-still of the fork is noted. This would 
show, for example, that the large C^fork has sounded for 72 seconds 
from the moment of covering at the lowest division line until the end. 
Using the fork at a clinical examination, it is allowed to sound until 
the triangles are covered at the established division line; at that moment 
the fork is brought to the patient's ear and note is taken of how long he 
can perceive the sound. Knowing that a normal ear can perceive the 
sound for 72 seconds, counting from the established division line, it is 
very easy to determine the degree of shortened perception without its 
being necessary to compare again the time of perception with that of 
the normal ear at the time of examination. 

4. The Kittlitz-Bernd Fork. — The instrument devised by Kittlitz 
at Bloch's instigation may be used for forks of different pitch, but is 



80 THE DISEASES OF CHILDREN 

best suited for the unweighted c ! -fork of Edelmann. It is easier to read 
off the result from this device than from that of Gradenigo. Latterly 
the Kittlitz fork has been considerably improved upon by Bernd. 

In spite of a number of experiments, it is impossible to express the 
hearing acuity in exact percentage, it being necessary to content one's self 
with stating the degree of shortening in seconds and the approximate 
percentage. In many cases it is sufficient to distinguish between four 
degrees of pathological perception of the tuning-fork, as follows: (a) 
slight shortening, (6) medium or moderate shortening, (c) considerable 
shortening, (d) no perception (sound-deafness). 

III. TEST OF CRANIAL-BONE CONDUCTION BY NOISES 

(1) Watch-test. — The ticking of a watch is distinctly heard by the 
normal ear from any part of the cranial bones up to the age of 40, and 
at least from the mastoid up to the age of 50. Suppressed perception of 
the ticking through the cranial bones points to an affection of the sound- 
perceiving apparatus. Although the watch-test is not of very great 
practical importance, it is nevertheless an appreciable adjunct in con- 
nection with the other functional tests. Affection of the sound-perceiving 
apparatus can, however, not be diagnosed therefrom unless there are 
other symptoms pointing to an involvement of the inner ear. Younger 
men, with a perfectly normal sense of hearing, may in exceptional cases 
fail to perceive the ticking of a watch through the cranial bones, while 
in children the test may be negative from want of attention. Neuras- 
thenics are sometimes under the impression of hearing the ticking, but 
control with a stop-watch will immediately disclose the real state of 
things, since the patient will still believe he can hear the watch ticking 
after it has been stopped. 

Testing for distance by means of a watch through air conduction 
is of no practical importance. 

(2) Testing with Politzer's Acoumeter. — The acoumeter represents 
a very simple means of establishing the degree of hearing acuity so far 
as noises are concerned (see p. 67). It is of less importance for testing 
cranial conduction, seeing that the comparatively loud noise produced 
by the acoumeter would only be inaudible in considerably advanced 
stages of affection of the inner ear, and patients frequently experience 
difficulty in separating the tactile from the hearing sense when the 
apparatus is in motion. 

IV. DEMONSTRATION OF UNILATERAL DEAFNESS 

It was pointed out in the section on the Physiology of the Ear 
that it is impossible to isolate completely the function of one ear to the 
exclusion of the other, either by way of air or cranial conduction. Even 



THE FUNCTIONAL HEARING TEST 81 

when the external meatus is closed in the most laborious manner by 
filling it with glycerine and plugging it with cotton, the sound-conduction 
to that ear will not be completely suppressed. Besides, in the functional 
test of one ear there is no way of preventing the other ear from partici- 
pating in the perception of sound by way of cranial conduction. 

We are, therefore, content in the monaural test to have the meatus 
of the other side closed with a moistened finger tip, although this will 
not prevent the examined person from correctly repeating words spoken 
in conversational language at a distance of from 6 to 10 yards. This 
can be easily demonstrated in a normally hearing individual by plugging 
both ears. 

If in a case of unquestionable unilateral total deafness the normal 
ear is plugged as described, the deaf ear will have an apparent acuity 
of 1-2 yards for conversational language. Accordingly, we arrive at 
the following rule: If, on examination, we find an acuity of 2 yards C, 
or less, in one ear, it will be necessary to test this ear by itself, in order to 
ascertain whether this is the actual hearing distance or whether the ear is 
totally deaf and the apparent hearing distance is only the result of func- 
tional cooperation of the other side which cannot be entirely excluded. 

The following methods serve to establish unilateral deafness : 

i. Testing with the Hearing Tube. — When speaking the test words 
through a long hearing tube into the ear to be examined, cranial conduction 
to the other ear will be of less importance than in the ordinary arrange- 
ment, as only easy and isolated words can be perceived by the opposite 
ear, which is closed with a finger. I have used for a number of years a 
rubber tube 4 meters long and 1.5 cm. clear diameter, fitted with a metal 
olive and a hard rubber funnel. If conversational language and whisper- 
ing, or conversation alone, are still distinctly heard, and if the test 
words are promptly and correctly repeated, it shows that the examined 
ear has still a positive sense of hearing for language. Should only some 
of the words be understood, or none at all, or should there be any hesi- 
tation or mistakes, a diagnosis of deafness for spoken sounds is justified. 

2. Test with the Unweighted a ! -Fork. Bezold's Test. — This test 
was recommended by Bezold as a simple means of establishing unilateral 
deafness for spoken sounds. Bezold-Edelmann's a'-fork is best suited 
for this test. Its pitch is high enough to be used as a test for the cochlea, 
and yet deep enough to be heard by the other well-plugged ear by way 
of air conduction. As a matter of course, this test is only carried out 
for air conduction. 

The value of this method consists in the following: Perception of 
the a ! -fork, even though considerably shortened, is a conclusive proof 
of functional ability of the tested ear. Complete absence of perception 
for air conduction in this test can only be regarded as a proof of deafness 

Vol. VI— 6 



82 THE DISEASES OF CHILDREN 

if the result of the other tests points to unilateral deafness. For clinical 
purposes the attest should preferably be combined with Stenger's test 
(see below). 

3. Stenger's test requires two tuning-forks of precisely identical 
pitch. The test for the normal ear is conducted in the following way: 
One of the forks is held in front of the healthy ear at a distance of 6-8 
cm., the patient, of course, stating that he perceives the sound on that 
side. Upon bringing the second fork, while sounding, near the other ear 
at a smaller distance, say 4-1 cm., while the position of the first fork 
remains unchanged, the sound will only be heard by the ear which is 
nearer a fork. On removing the latter, the original perception is restored. 
It is possible, therefore, to suppress the perception of the first ear by 
closer approach of an identical fork to the meatus of the other ear. If it 
is desired, for instance, to test for right-sided deafness, one of the forks 
is held at a distance of 6-8 cm. from the left meatus; the second fork is 
then brought as near as possible to the meatus of the right ear. Should 
the latter possess functional hearing ability, the perception of the left 
side would be suppressed as the right fork is being approached, and the 
patient will state that he can hear the sound only with his right ear. On 
removing the fork from the right ear, perception of the left ear immedi- 
ately reappears. Should, however, the right ear be actually deaf, even 
the closest approach of the second fork to the right ear will remain without 
effect, and the patient will state that lie has heard the sound from the 
left side without interruption. 

It is advisable in this as well as in all other tuning-fork tests that 
the examiner stands erect behind the patient, who sits down, in order 
to avoid error and confusion. Nor should the patient be allowed to 
know that two forks are being employed. 

Stenger's test is not only interesting theoretically, but is also of 
clinical value in that the method of questioning is uncommonly simple, 
the patient having merely to state whether he hears the sound on the 
right or left side. The difficulty patients experience in stating whether 
or not they still perceive a sound (as in the tuning-fork tests), or in 
indicating the precise moment when they cease to perceive a vanishing 
sound, is entirely done away with. Stenger's test is very valuable and 
indispensable for the demonstration of unilateral deafness, but the two 
forks used should be of exactly identical pitch. Personally, I always 
use Bezold-Edelmann's unweighted a^forks and combine the Stenger 
and Bezold tests. 

Complete uniformity of two tuning-forks is established in the 
following way: Strike one of the forks and approach with it the silent 
one with prongs parallel, and the second fork will commence to covibrate 
if of identical pitch. 



THE FUNCTIONAL HEARING TEST 83 

4. Alarm Instruments. — Barany has devised an alarm drum, Neu- 
mann a galvanic alarm instrument, Voss a water jet bellows, for the 
purpose of creating a great noise with the intention of excluding the 
physiological cooperation of the healthy ear when testing for deafness 
of the other one. 

V. DEMONSTRATION OF SIMULATED HEARING INSUFFICIENCY, SIMULATED 
UNILATERAL AND BILATERAL DEAFNESS 

Simulated hearing insufficiency with normal function of the ear is 
recognized by the fact that the result of the functional test does not 
agree with that of the test for distance. The tuning-fork test will often 
be perfectly normal, so that there is no basis whatever in the clinical 
functional findings for the alleged hardness of hearing. Another im- 
portant sign is the complete absence of a combination field, and the 
method in which the individual repeats the test words. The patient's 
eyes being bandaged, he will make contradictory statements by profess- 
ing inability to understand words spoken close by, while others, spoken 
at a greater distance, are perceived. There is hesitancy in repeating, 
although the words are spoken within positive hearing distance, the 
object being to create the impression that there was difficulty in catch- 
ing them. He innervates the facial and appears to listen with the closest 
attention. He requests words to be repeated, and responds by repeat- 
ing at first nothing but the article, then the first syllable, and so on, 
until at last he repeats the entire word. A genuine patient never acts 
in this way : he will combine when hearing indistinctly, but he will never 
be able to piece words together syllable by syllable. 

It is a more difficult task to recognize aggravation. This implies 
that a person hard of hearing simulates a higher degree of insufficiency 
than really exists. It may be a matter of great difficulty to establish 
the true degree of hearing insufficiency, especially if the patient has been 
examined before on several occasions and is careful enough not to overdo 
his exaggerations. However, experience on the part of the examiner, 
repeated examination with bandaged eyes and on different days, will 
usually disclose the facts. 

Exposure of simulated unilateral deafness does not present any 
serious difficulties. If the other ear is normal, suspicion will be aroused 
by the patient pretending not to hear words spoken closely to the sup- 
posedly deaf ear in the monaural test, knowing as we do that in total 
unilateral deafness and normal hearing on the opposite side (which is 
closed with a moistened finger) there is still an apparent hearing distance 
of at least 1 yard C. Another aid is Stenger's test, which is based on 
the fact (first discovered by Politzer) that, with equal quality, the 
weaker sound-perception is eliminated by the stronger. 



84 THE DISEASES OF CHILDREN 

The test in such a case is made as follows: Two a 1 - or c^forks are 
used. One is held at a distance of 6-8 cm. before the normal ear, after 
which the other one is gradually approached toward the supposedly 
deaf ear at the closest possible range. The patient, with bandaged 
eyes, the examiner standing behind him, is requested to state on which 
side he perceives the sound. If the ear is really deaf, the sound will, 
of course, be perceived at the sound side; if, however, deafness is 
simulated, the closer approach of the fork toward the supposedly 
deaf ear will have suppressed the perception on the first side. The 
individual positively perceives the sound by the supposedly deaf ear, 
but, since he feigns deafness in that ear, will pretend not to hear any 
sound at all. 

Further valuable assistance is given by a survey over the entire 
system of functional tests: 

In unilateral deafness the results of the tuning-fork tests, hearing 
distance, etc., are very characteristic: the findings will always disclose 
an affection of the conducting and perceiving apparatus, or of the latter 
alone, since an affection limited to the sound-conducting apparatus 
can never cause deafness. In simulation the statement of functional 
facts is full of contradictions, and on going into details of the results of 
the functional tests it will not be difficult to narrow them down so as to 
form a basis for the diagnosis of simulation. 

The simulation of bilateral deafness or deaf-mutism may cause 
considerable diagnostic difficulties. 

It is important to observe the behavior of the patient. A genuinely 
deaf person will anxiously look about, closely watch our lips during 
conversation in order to read the words therefrom. These patients are 
elated at the least ray of hope we give them and could be easily persuaded 
to undergo treatment. 

The simulator^ on the other hand, looks apathetic or recalcitrant, 
especially if he has already undergone several examinations and believes 
that he has had the best of it. He stands with downcast eyes, avoiding 
to look into your face. From the first we are imperiously informed that 
only written conversation can be carried on, and a formidable array of 
note-books are produced to substantiate the statement. He requires 
neither treatment nor improvement. He has no time for treatment, 
as he is "just off for a trip " or he "does not live in town" : all he requires 
is a certificate stating that he is stone-deaf. Young persons are usually 
exposed in a short time, and, on getting excited, they fling writing to 
the winds and react to conversation. 

At the same time, attempts to force a sudden exposure are not 
advisable. In making the remark, "Very well, I can see you are really 
deaf, you can go," we may involuntarily accompany our words by move- 



THE FUNCTIONAL HEARING TEST 85 

ments or gestures which are correctly interpreted by a genuinely deaf 
person, and the fact of his responding to them is no proof of simulation. 

In difficult cases it will be necessary to keep the patient under 
observation for some time when he thinks himself unobserved, in the 
street, at home, etc. 

The authorities are also a reliable source of information. I am in 
the habit of investigating patients' personal affairs at their place of 
birth, sending a question blank to the local authorities with a request 
to fill in all valuable data on school attendance, communications of 
teachers, employers, etc. 

In apathetic subjects who are supposed to have acquired deafness 
at a later period, and in those where there is a combination of alleged 
deafness and an affection of the brain, notably idiocy, it may be difficult 
or impossible to decide whether there is deafness or simulation. I have 
been completely at a loss to make up my mind in a few cases of idiocy 
which had not reacted to any noise whatever for a number of years as 
to the genuineness of the aural affection. 

There is a difference between diagnosing aggravation or simulation 
and convincing the accused of the fraud. The diagnosis is positive in 
many cases on the basis of functional findings, and yet the person in ques- 
tion may not be willing to admit that he is shamming. At the same time, 
the absence of admission is of no consequence from a diagnostic point of 
view, and personally I do not care whether I obtain an admission or not. 

The patient should under any circumstances be very civilly treated 
during the examinations. It would be wrong to create the impression 
that his statements are distrusted or that there is an attempt to expose 
him. If simulators find their position untenable, they are apt to leave 
brusquely and decline any further examination, thus rendering the com- 
pletion of a logical diagnostic structure impossible. As soon, however, 
as we are able to make the diagnosis on the basis of the facts we have 
elucidated, we may try to persuade the simulator to admit his false posi- 
tion. This is best accomplished by a kindly talk. We explain to him 
that we have established the positive fact that he is shamming, adding 
that we will now repeat the functional test, to which he is requested to 
pay the closest possible attention. Such an appeal is generally successful. 

Furthermore, the suspicion of simulation should not be too readily 
entertained. I always give supposed simulators the benefit of the doubt, 
unless there is direct proof to the contrary, furnished by contradictory 
statements in the functional test. Even when confronted with some 
irregularity in the results, allowance should be made in children for 
becoming fatigued and in adults for neurosis or hysteria. As to methods 
applicable in exposing frauds, I refer to Politzer's text-book and Ham- 
merschlag's "Compilations." 



VI. FUNCTIONAL EXAMINATION OF THE SEMICIRCULAR 
CANALS AND THE VESTIBULAR APPARATUS 

i. LABYRINTHINE NYSTAGMUS AND THE METHODS OF ITS OBSERVATION 

In the functional examination of the static labyrinth it is neces- 
sary to establish the labyrinthine reflex excitability and to observe the 
presence or absence of labyrinthine manifestations of excitability. 

In order to find out whether nystagmus is present, one of the eyelids 
is slightly raised, and patient is requested to look at an object 1-2 yards 
distant, first in a straight line, then toward the right and left. Spontane- 
ous nystagmus, if present, is bilateral in the majority of cases and of equal 
character in both eyes. Horizontal nystagmus is diminished by increased 
convergence, while nystagmus of less intensity can hereby be completely 
suppressed. In labyrinthine nystagmus the rhythmic movements of the 
bulb are composed of an intense movement toward one side and a less 
intense slow movement toward the other side, and the nystagmus is 
designated by the direction of the more pronounced movement. Hence 
the expressions "nystagmus to the right" and "nystagmus to the left." 

In regard to the movements of the bulb in straight nystagmus, in 
which the bulb is displaced in a straight line, we distinguish horizontal, 
oblique, and vertical nystagmus. If the bulb rotates, we designate the 
nystagmus as rotatory. In many cases the entire movement is composed 
of a rotatory and a horizontal contingent. This is called horizonto- 
rotatory nystagmus, or rotatory nystagmus with a horizontal compo- 
nent, or horizontal nystagmus with a rotatory component, according to 
which component preponderates, if any. 

According to the extent of the twitchings, we distinguish between 
fine and coarse, rapid and slow nystagmus. Exact figures, if desired, 
must be established by counting per minute. The intensity of the 
nystagmus is established by the relation existing between nystagmus 
and direction of vision. Nystagmus of slight intensity is only demon- 
strable with vision toward the same side; for instance, nystagmus of 
slight intensity to the right can only be demonstrated with vision to the 
right (first degree of intensity). The second, or medial degree of inten- 
sity, is present if there is nystagmus with vision toward the same side 
and with straight vision (looking at an object several yards distant or 
without fixation behind Abels's spectacles). In the third and highest 
degree of intensity, nystagmus is entirely independent of the direction 
of vision and is demonstrable in any position of the bulb, including 
vision toward the opposite side. Thus, nystagmus to the left will not 
be inhibited by vision to the right. 
86 



EXAMINATION OF SEMICIRCULAR CANALS 87 

2. SPONTANEOUS LABYRINTHINE NYSTAGMUS 

Pathological nystagmus, which occurs in certain affections, is also 
called spontaneous nystagmus, of which we distinguish three forms: 
(1) In many affections of the labyrinth, nystagmus to the right occurs 
upon vision to the right, and nystagmus to the left upon vision to the 
left. This is designated nystagmus toward both sides, or nystagmus in 
the end-positions of the bulb. (2) Nystagmus toward the affected side 
is recognized by the twitchings occurring toward the affected aural side. 
(3) If there is pronounced nystagmus toward the opposite (healthy) 
aural side, we so designate it. 

Spontaneous nystagmus toward both sides is always of slight in- 
tensity. It never exceeds the first degree above referred to, while the 
other two forms of spontaneous nystagmus may reach any degree of 
intensity. It is advisable, therefore, in all cases first to test for spon- 
taneous nystagmus with lateral vision, and then to establish the behavior 
of vision to the right, straight, and to the left. In normal individuals 
there is no spontaneous labyrinthine nystagmus. Nor is it demonstra- 
ble in many pathological cases where the semicircular canals on both 
sides have been destroyed a considerable time ago. In all other cases 
the pathological condition of the semicircular canals is demonstrated 
by the presence of spontaneous nystagmus. 

In regard to the relation of the spontaneous nystagmus to the other 
labyrinthine symptoms, to the reflex excitability of the labyrinth and 
hearing acuity, the reader is referred to the chapter on inflammatory 
affections of the labyrinth. 

3. LABYRINTHINE NYSTAGMUS AND VERTIGO AS DIFFERENTIATED FROM THE 
OTHER FORMS OF NYSTAGMUS AND VERTIGO 

Labyrinthine nystagmus is characterized by the fact that the 
rhythmical movements of both eyes occur simultaneously and that the 
forward (first) movement is always more intense than the backward 
(second) movement. This fact will enable even the less experienced 
easily to recognize and describe a labyrinthine nystagmus from its 
direction. If the labyrinthine nystagmus is of slight intensity, it is 
only demonstrable with vision toward the same side, while none but 
high degrees of intensity can be demonstrated with straight vision. The 
highest degree of intensity is demonstrated by the fact of nystagmus 
being independent of the direction of vision, so that it can be distinctly 
observed in any position of the bulb. In slight degrees of intensity, 
labyrinthine nystagmus is only occasionally visible, notably at the 
time of vertigo, or it may be entirely absent. If, finally, in spon- 
taneous labyrinthine nystagmus, vision is repeatedly directed toward 
the same side, alternately to the right and left, there will usually be 



88 THE DISEASES OF CHILDREN 

rapid diminution of the nystagmus, sometimes entire suppression of 
it for a time. 

Congenital nystagmus can be easily distinguished from the laby- 
rinthine form. It is composed of oscillating or undulating movements, 
there being no particular intensity toward any side. Congenital nys- 
tagmus is usually coarse and of high intensity, so that it can often be 
distinctly observed at a distance of several yards. It is not associated 
with vertigo. 

Optical nystagmus has the following characteristics as compared 
to the labyrinthine form: It can be traced to definite ocular affections 
(affections of the orbital muscles, anomalies of bulbar development, 
anomalies of refraction), provided it is caused by a pathological factor 
situated within the orbit itself. Optical nystagmus, caused by fixed 
contemplation of objects in motion, disappears on closing the lids or by 
simply discontinuing fixation temporarily or entirely. 

Neurotic or neurasthenic nystagmus occurs only with extreme 
lateral vision and is considerably increased by repeated intense vision 
toward the right and left. 

Labyrinthine vertigo occurs by subjective, illusory oscillations, which 
are more frequently perceived as rotations of the surroundings than of 
the patient's own body. In the latter case the direction of rotation 
usually corresponds to that of the nystagmus ; in the former case rotation 
appears to be in the opposite direction. The details of an attack of 
vertigo will be remembered by the patient more clearly if the attack was 
severe and continuous; otherwise the rotatory movements will not be 
retained in the memory as a characteristic occurrence or no notice may 
be taken of them at all. If the attack was severe, not only the fact of 
the oscillations but also their direction will be remembered. The prin- 
cipal deuteropathic manifestations of labyrinthine vertigo are the re- 
active movements caused by vertigo, the totality of which is summarized 
as objective vertigo. The reflex movements are sequelae of reflex muscle 
innervation, and their principal purpose is to restore the equilibrium 
which has seemingly been disturbed by the rotatory vertigo. 

If the reactive movements are sufficiently pronounced, they will 
culminate in objective vertigo. Further reactive manifestations, which, 
however, occur only in very severe paroxysms of vertigo, are muscular 
spasms and vomiting. 

In objective vertigo there is always an acute reflex change of the 
muscle tonus, caused by the labyrinth. The tonus of the labyrinth is 
probably produced by the labyrintho-cerebral tracts, and its absence is 
followed by impairment of the coarse forces and faulty precision of 
movements. 



EXAMINATION OF SEMICIRCULAR CANALS 89 

Labyrinthine vertigo is always associated with nystagmus. If 
labyrinthine nystagmus persists for a long time, especially if its intensity 
remains unchanged or is but slowly reduced, vertigo is arrested after a 
relatively short time, while the nystagmus will persist for many weeks or 
months longer. Both intensity and movements of labyrinthine nystag- 
mus vary in individual cases; nor can any general statement be made as 
to the patient's becoming accustomed to nystagmus. 

The further consequences of objective vertigo are disturbances in 
equilibrium and gait, which can seldom be tested clinically, for the 
reason that the very presence of vertigo prevents patients from walking 
or even standing. However, we may summarize the characteristic equi- 
librial disturbances of the labyrinth as those which occur independently 
of vertigo and are persistent in character. 

Labyrinthine vertigo is differentiated from the optical form in that 
the latter is immediately arrested by closure of the lids, in many cases by 
merely relieving or abandoning fixation, whereas labyrinthine vertigo 
is but slightly reduced by closure of the lids, if at all. Although neuras- 
thenic or neurotic vertigo may sometimes simulate the labyrinthine 
form, there are no insurmountable difficulties in their differentiation. 
Labyrinthine vertigo is greatly dependent upon the position of the head, 
and occurs in affections of the labyrinth on arising in the morning and 
changing the recumbent position into the erect. The movements of 
the head in washing the face are likewise apt to produce this form of 
vertigo. The neurotic form, on the other hand, is independent of the 
position of the head, or, at any rate, is not so mechanically dependent 
upon it as labyrinthine vertigo. The neurotic form, combined with 
other nervous symptoms (oppression, etc.), preferably occurs in the 
evening after physical and mental fatigue, or perhaps in the street 
during the day. 

Vertigo is sometimes complained of in cardiac affections or anaemia. 
These manifestations, however, amount, as a rule, to fainting fits rather 
than vertigo. In most cases patients describe the ground as giving way 
or having undulatory movements, or they complain of blackness before 
their eyes. The attack is usually produced by muscular work or physical 
exertion. Every paroxysm of cardiac vertigo is associated at least with 
transitory impairment or else complete loss of consciousness, while the 
sensorium remains undisturbed in the labyrinthine form. 

Cerebellar vertigo is always associated with cerebellar ataxia and 
homolateral disturbances of coordination. It occurs in the shape of 
violent paroxysms, but any characteristic feeling of rotation either of 
the patient's own body or his surroundings has not been observed in 
this form. 

Tabetic vertigo requires careful judgment, as in many of these 



90 THE DISEASES OF CHILDREN 

cases there is not only an affection of the segmental nerves, but also of 
the eighth nerve and labyrinth. There are degenerative changes of the 
labyrinth and auditory nerves in many cases of tabes, and it is therefore 
not surprising if these patients combine attacks of true labyrinthine 
vertigo and equilibrial disturbances with the peculiarities of the tabetic 
gait. In other tabetic cases, however, patients have vertigo without 
impairment of the labyrinth. Close questioning, however, shows that 
in these cases the expression "vertigo" is confused with "equilibrial 
disturbance," and careful examination (Romberg-Erben's test) will 
show that in so-called tabetic vertigo there is only a disturbance of the 
equilibrium, but no sensory illusion as to the topography of the body 
or its surroundings, provided the labyrinth is normal. 

Vertigo may also be caused by the lower sensory organs (smell, 
taste, feeling). These are manifestations of neurotic origin or slight 
fainting fits of short duration. 

A. EXAMINATION OF THE SEMICIRCULAR CANALS 

The object of all functional tests is to establish the reflex excita- 
bility of the semicircular canals. The reflex symptoms of an irritation 
of that apparatus consist in nystagmus, vertigo, disturbed equilibrium, 
muscular spasms, and vomiting, and among these nystagmus has proved 
the most valuable for clinical examination, vertigo being only of inferior 
importance. The point, therefore, is to observe and interpret labyrin- 
thine nystagmus produced by the irritation 

i. Examination on the Rotatory Chair (Fig. 49). — Formerly reflex 
vertigo was the object of the test; later it was found necessary to examine 
during rotation in order to find out the function of the semicircular 
canals, — i.e., the patient had to rotate with the examiner, who had to 
make observations in spite of his own vertigo. At the present time we 
are able to use reflexes for diagnostic purposes which occur after rotation 
has been arrested, thanks to an exact study of after-vertigo and after- 
nystagmus. The rule is to rotate the patient on the chair about 10 times 
with increasing speed (positive acceleration), after which the motion is 
suddenly arrested. This will produce nystagmus to the left after rota- 
tion to the right, and nystagmus to the right after rotation to the left. 
There will be rotating nystagmus if the head is inclined toward rotation, 
or horizontal nystagmus if it is kept erect. In this experiment the normal 
duration of after-nystagmus rarely exceeds 15-40 seconds. Nystagmus 
to the left is nearly always referable to the irritated condition of the left 
labyrinth, and nystagmus to the right is referable to the right labyrinth. 
From this it follows that the rotation should be to the right for testing 
the reflex excitability of the left ear, and vice versa. 

The degree of excitability is indicated by the duration of the after- 



EXAMINATION OF SEMICIRCULAR CANALS 



91 



nystagmus. Normal excitability exists if the after-nystagmus lasts for 
15-40 seconds in cases presenting no pathological symptoms of the static 
labyrinth. Shorter or longer duration of the nystagmus is individual 
and not pathological, provided there is no affection of the labyrinth and 
an examination of the opposite labyrinth leads to the same result. 

In the presence of clinical symptoms of the labyrinth we speak of 
pathologically diminished excitability if the nystagmus lasts less than 
15 seconds after 10 rotations, while the excitability is called prolonged 
(increased) if the nystagmus lasts FlG 49 

for more than 40 seconds or if it 
lasts at all longer than the nys- 
tagmus of the opposite labyrinth 
after irritation. 

Nystagmus produced by rota- 
tion is always examined in that 
direction of vision in which sponta- 
neous nystagmus, if present, would 
not be visible, in order to prevent 
interference with the latter. This 
is best accomplished with straight- 
forward vision. If there is intense 
spontaneous nystagmus, the direc- 
tion of vision in which the spon- 
taneous nystagmus cannot be ob- 
served is established before the ex- 
amination. (Barany's head-holder.) 

Should there be no nystagmus 
after 10 rotations, the reflex excita- 
bility of the semicircular canals is 
regarded as extinct (excitability neg- 
ative). Slight irritation of the op- 
posite labyrinth, however, may in 
these cases cause slight nystagmus 
lasting for 6-8 seconds. 

The great clinical importance 
of examination on the rotating chair 
is its simplicity and the utility of establishing functional irritations. 

2. In the caloric test functional irritation is replaced by thermal 
irritation. Irrigation of the auditory meatus or middle ear with water 
below body temperature (70-85° F.) will cause rotatory nystagmus 
toward the opposite side, irrigation with water above body temperature 
(104° F.) toward the irrigated side. The time for the reaction to set in 
depends upon the condition of the tympanic membrane. If intact, 




Rotating chair. 



92 THE DISEASES OF CHILDREN 

irrigation will have to be continued for some time; if destroyed, the 
caloric irritation will act immediately upon the lateral wall of the laby- 
rinth and only short irrigation will be required. The reaction is explained 
by the fact that thermal irritation causes an endolymphatic current and 
an associated motion (oblique position) of the cupola, as it does on the 
rotating chair, and the direction of the current after elevation of tem- 
perature is opposite to that after cooling. The caloric test is valuable 
because it enables the examiner to test the semicircular canals separately 
on each side. 

B. METHODS OF EXAMINATION OF THE SEMICIRCULAR AND 
VESTIBULAR APPARATUS 

i. The Galvanic Test. — The semicircular and vestibular apparatus 
are tested by the galvanic current, which apparently excites all the rami 
of the nervus vestibularis and all the nerve-end places of the static 
labyrinth, so that in the present state of our knowledge we are unable 
to differentiate between the semicircular and vestibular apparatus by 
the galvanic test. 

The test is made as follows: The cathode is placed against the 
tragus immediately in front of the external meatus or against the pos- 
terior margin of insertion of the concha. The anode is placed either in 
the nape of the neck, against the chest, or in the patient's hand. As 
the circuit is closed at an average strength of 4 ma., there will be a 
rotatory nystagmus toward the cathode; if the circuit is opened, there 
will be a short-beating nystagmus toward the opposite side. If the 
anode is at the ear, nystagmus toward the opposite side will occur on 
closing the circuit, and nystagmus toward the same side when the circuit 
is opened. The nystagmus should be established with straightforward 
vision, but it is easier if the patient is placed in the direction of the 
nystagmus and ordered to look away laterally. A current applied at 
greater strength than 4 ma. in a normal individual will cause objective 
vertigo, as evidenced by movements of the head and body and a tendency 
to fall. These movements occur in the opposite direction to that of the 
nystagmus, which means toward the anode. In cases of pathologically 
increased excitability of the semicircular canals the positive galvanic 
reaction may occur at 1 or 2 ma. 

As a rule, the reaction will occur more rapidly and distinctly with 
the cathode at the ear than with the anode, the cathode-nystagmus 
being more distinct than the anode-nystagmus. In pathologically 
reduced or destroyed excitability of the labyrinth, the positive galvanic 
reaction will only set in at a current strength of from 6-13 ma., always 
provided the vestibular nerve is still capable of reacting upon the 
galvanic irritation ("trunk reaction" of Ewald). Should this no longer 



EXAMINATION OF SEMICIRCULAR CANALS 93 

be the case, the vestibular galvanic reaction will be negative, and this 
would indicate that not only the peripheral end-apparatus, or labyrinth, 
has lost its function, but the nerve also. The normal points of attack of 
the galvanic current are the sensory epithelium and the nerve. With 
intact condition of these two points, there will be normal reaction at an 
average strength of 4 ma.; with pathologically increased excitability of 
the labyrinth, the positive reaction will occur at less than 4 ma.; and 
with a pathologically reduced or destroyed excitability of the labyrinth, 
the positive galvanic vestibular reaction will occur at a current strength 
of 7-15 ma., as long as the vestibular nerve is still capable of conduction. 
With the vestibular apparatus and nerve destroyed, the galvanic reaction 
will be negative, and there will be no nystagmus even at the highest 
applicable current of 15-30 ma. 

The galvanic test enables us to separate the condition of the periph- 
eral apparatus from that of the nerve for diagnostic purposes, and this 
constitutes its particular value. 

2. Examination of the Mechanical Reflex Excitability (Nystagmus 
from Compression and Aspiration, Kuemmel's Symptom of Pressure 
Variation, Fistular Symptom). — This test requires the use of a laterally 
perforated bulb, as in Gelle's test, or a small double bulb. The external 
auditory meatus is closed air-tight with the moistened bulb, when 
neither compression (elevation of pressure) nor aspiration (reduction of 
pressure) will produce a vestibular reaction, nystagmus or vertigo, under 
normal conditions. If, on the other hand, there is a fistular perforation 
of the osseous capsule of the labyrinth at a place accessible from the 
middle-ear spaces, both elevation and reduction of pressure will cause 
nystagmus. Nystagmus produced by compression is in the opposite 
direction to that produced by aspiration. 

In typical cases the nystagmus thus produced consists of but few 
extensive twitchings, accompanied by considerable vertigo. In some 
cases pressing the tragus into the auditory meatus will sufficiently elevate 
the air pressure to cause the distinct fistular symptom. The mobility of 
the stapes is considerably increased by the destruction of the incus- 
stapes articulation, and this may suffice to cause nystagmus by com- 
pression and aspiration without there being a fistula in the labyrinth. 
In cases of congenital or prematurely acquired anomalies of the internal 
ear (syphilis of the labyrinth) nystagmus may likewise be produced by 
compression or aspiration. 

C. METHODS OF TESTING THE VESTIBULAR APPARATUS 

I. Testing the Equilibrium of the Body and the Disturbance of 
Vestibular Equilibrium. — The stability of the body is first tested by 
Romberg's method. The patient is then required to stand on one leg, 



94 THE DISEASES OF CHILDREN 

to walk forward and backward, and, if the patient is young, agile, and 
gymnastically trained, to hop forward and backward. Normal persons 
can perform these movements by the aid of the labyrinth, the eye, and 
the deep and superficial sensitiveness, these being the three components 
that go to make up the stability of the body. In order to accomplish 
these movements, however, two of these three components are sufficient, 
as in normal individuals standing, walking, or hopping is not impaired 
by closing the eyes. Even in pathological changes of the vestibular 
apparatus there may still be apparently good equilibrium, but if such 
an individual closes his eyes, there will be only one stability component 
—deep and superficial sensitiveness — to draw upon, and the defective 
equilibrium will be at once apparent. In cases of affected labyrinth, 
therefore, it is possible to establish the want of equilibrium by following 
this order of arrangement. This impaired equilibrium, however, has 
nothing to do with the temporary, secondary disturbances of stability 
caused by vertigo of the labyrinth. 

2. The Goniometer Test. — The object of this test is to examine 
the stability of the body on an inclined plane. The patient stands with 
bare feet on the goniometer board, which is strewn with sand to afford a 
safe foothold. The patient assumes the Romberg position, and can 
thus, if normal, bear an incline up to 30° in any erect position, whether 
the board is raised in front, behind, at the right or left side (Kuemmel). 
If the equilibrium is moderately impaired without accompanying vertigo, 
there may be a decrease of stability with open eyes, but an angle of 30° 
can still be borne. Shutting the eyes, however, will at once disclose the 
defect. In some cases an incline of no more than a few degrees will be 
borne with eyes closed. The limit is reached when the patient can no 
longer keep his balance, seems liable to fall, or holds on with his hands 
to keep erect. For clinical purposes, therefore, the result of the test 
with open and closed eyes has to be taken into consideration. Nervous 
and frightened individuals may sometimes not be able to tolerate the 
maximum incline, but in these there will be no difference between the 
results with open and closed eyes; besides, the tolerance will often im- 
prove when the test is repeated. 

3. Test for Counter-rolling of the Eyes. — In normal individuals 
counter-rolling of the eyes will occur when the head is laterally inclined. 
The vertical meridian of the bulbi remains unchanged with only moderate 
lateral inclination, while with exaggerated lateral inclination the simul- 
taneous movement of the meridian is considerably diminished from the 
effect of counter-rolling. At an inclination of 45° counter-rolling amounts 
to 12-15° (Barany), and slightly increases at a greater inclination. When 
the labyrinth is destroyed, counter-rolling is considerably reduced, to 
from 3° to 5°, or entirely suppressed. 



EXAMINATION OF SEMICIRCULAR CANALS 95 

Vestibular Disturbance of Gait 

In destruction of both labyrinths there is permanent impairment of 
equilibrium, which causes the patient to adopt a broad manner of walk- 
ing, which corresponds to the permanent positive Romberg test in cases 
of bilateral destruction of the labyrinth 1 ; the object in walking with the 
lower extremities extended is to counteract the reduced stability fol- 
lowing upon the destruction of the labyrinths. Deaf-mutes affect a 
dragging, noisy gait, as it assists their want of stability, and besides 
they are unable to hear the unpleasant noise their method of walking 
causes. 

In patients with diseased labyrinths the disturbances of gait be- 
come more pronounced in the stage of vertigo. In violent attacks of 
vertigo patients are unable to walk or to stand, or sometimes to assume 
a sitting posture in bed. In the latter case they select a position which 
causes the least degree of vertigo. This is always the one in the direction 
of the least nystagmus, and they exhibit great anxiety to retain it. As 
long as these patients are able to walk about, any attack of vertigo will 
cause them to deviate from a straight course, especially when walking 
with closed eyes. At first they will always deviate in the direction of 
the nystagmus when their eyes are closed. In the presence of pronounced 
vertigo they will also walk in that direction with their eyes open. This 
tendency, however, may change after a time. They will half-instinctively 
correct the deviation after they have once become aware of it, and this 
may eventually enable them to walk in a perfectly straight line. Fre- 
quently, however, there is overcorrection which will cause them to 
deviate in the opposite direction, while in undercorrection there may 
still be slight deviation toward the direction of the nystagmus. In cases 
of pronounced vertigo the correction will often change from one side 
to the other, leading to a more or less pronounced zig-zag walk. 

Labyrinthine and cerebellar disturbances of gait may be differen- 
tiated by the flank-walk test. Grasping the patient gently by the arm, 
we cause him to side-step with closed eyes. This can be accomplished 
toward both sides in patients with diseased labyrinths, while in cere- 
bellar affections the flank walk is considerably disturbed toward the 
side of the affection. Thus, patients with affections of the right cere- 
bellum will only with difficulty carry out the side-step to the right; 
their step is uncertain, there is danger of their falling down, being unable 
to make an initial step with the right leg. 

1 The tracks made by the feet are recorded by letting the patient walk barefooted over 
a sheet of paper 6-8 yards long and 1 yard wide after the soles of the feet have been moistened 
with liquid paraffin. The outline of the fresh traces may be marked with a colored pencil. 
They will be still more distinct if the soles have been smeared with a mixture of soot and 
liquid paraffin. 



96 



THE DISEASES OF CHILDREN 



Survey of the Acoustic and Static Tests 

I am in the habit of making a record of the tests for functional 
findings by availing myself of the chart reproduced in Fig. 50. It pro- 
vides for the findings of the hearing acuity (V, v, P), of the tuning-fork 
tests (IF, S, R, Ge), of the Galton-pipe test (Ga), of the watch test 
through the cranial bones (h), of the hearing-tube test (T), and of Sten- 
ger's test (St). The last two are used in testing for unilateral deafness. 

The results of the functional tests of 
the static labyrinth are also marked 

* opposite the corresponding abbrevi- 

* ations. 
This table is intended to record 

* the findings of the tuning-fork tests. 



Fig. 50. 



R. 



L. 



V 
v 
P 



w 
s 

R 

G£ 



Ga 



/ 



T 

St 



Fig. 51. 



' 13 20 20 30 50 76 55 75 65 32 40 54 20 12 




5p.N 
Ae 
T.N 
Ka.N 
G.N 
KO.N 
A.N 



+ + + + /H + + + + + + + + + 



C 2 G 2 Di A 1 G c a e 1 a 1 e 2 g 3 c 4 g* c 5 



Fig. 50. — Table for dotting in the findings of the functional tests. V, conversation (Vox) ; t>, whispering 
(vox); P, Politzer's acoumeter; W, Weber's test; S, Schwabach's test; R, Rinne's test; Gi, Gelle's test; Ga, Gal- 
ton pipe; h, watch test (hora) through the cranial bones; T, hearing-tube (Tube); St, Stenger's test; Sp. N, 
spontaneous nystagmus; Ae, disturbance of equilibrium (Aequil) ; T.N, nystagmus after rotation (Torsion); 
Ka.N, caloric nystagmus; G.N, galvanic nystagmus; Ko.N, compression nystagmus; A. N, aspiration nystagmus. 

The findings for the right and left ear are dotted in under the letters R and L. The two vertical lines serve 
to indicate the hearing distance both before and after physical treatment (air-douche, catheter). The method 
of dotting in the results of Rinne's test will be understood from the remarks on pages 72, 73, and from Fig. 48. 

Fig. 51. — Graphic representation of the quantitative tuning-fork tests based on Bezold's "acoustic relief." 



The letters designate the various tuning-forks of the Bezold-Edelmann 
series. The figures indicate the normal duration of perception in 
seconds, by giving the forks a maximum blow (C 2 and e 2 weighted). 
Shortening of the duration of perception by one-half is indicated by +, 
while the dots represent shortening by l-10th each. 

The example selected represents the findings with a medium ob- 
stacle of conduction. C 2 and G 2 could not be heard, D l was heard for 
2 seconds instead of the normal duration of 20 seconds, equal to a short- 
ening by 9-10ths, etc. The sounds e 2 -c 5 were heard for normal periods. 



VII. LOCAL ANAESTHESIA OF THE EAR 

Anaesthesia of the Ear. — There is no need to emphasize the impor- 
tance of anaesthetizing the external and middle ear, and it is useful to 
combine this proceeding with the induction of anaemia. Susceptibility 
to pain differs with the various parts of the ear, according to whether 
any particular part is normal, acutely inflamed, or recovering from 
some affection. Paracentesis can be almost painlessly carried out with 
a non-inflammatory tympanic membrane, for instance in suppurative 
otitis media, without requiring any particular preparation, and the 
same holds good for the resection of the posterior fold and other pro- 
cedures, while paracentesis with an inflamed tympanic membrane is 
exceedingly painful without local anaesthesia. Susceptibility to pain in 
the membranous part of the external auditory duct does not differ from 
the rest of the skin, while the osseous part of the duct is even normally 
very sensitive to pressure or puncture. Froschels has called attention 
to the possibility of subnormal susceptibility of the external auditory 
canal and the absence of the tickling reflex in otosclerosis. The normal 
and non-inflamed mucosa of the middle ear is but slightly sensitive to 
pain; exposed bone is completely insensitive. 

Generally speaking, it is easier to induce anaesthesia when the 
epithelial layer of the mucous membranes has been destroyed ; also in 
the presence of granulations, as compared to intact epithelial layers; 
in chronic as compared to acute cases of inflammation. In acute in- 
flammation of the tympanic membrane, anaesthesia takes better effect 
after treatment of the affected parts with acetic alumina or Burrow's 
solution, but the reverse is the case after treatment with carbol-glycerine, 
the reason being that the first two remedies loosen and macerate the 
epidermal layer of the tympanic membrane. 

Anaesthesia of the middle ear is easiest to induce in the meso- and 
epitympanum, more difficult in the hypotympanum, especially if the 
pathological changes have spread downward. Anaesthesia of the antrum 
and the tympanal ostium of the tube presents the greatest difficulties. 

Local anaesthesia may be induced in three different ways: (1) instil- 
lation of fluid media, (2) insufflation of powders, and (3) injections. 

For anaesthesia by instillation we use 5-20 per cent, solutions of 
cocainum hydrochloricum or its substitutes (novocaine, alypin). The 
solution is heated to 104°-108° F., and 5 drops of adrenalin solution 
(1 : 1000) are added to 1 c.c. shortly before use. When using the 20 
per cent, solution, a cotton plug should be saturated and pushed for- 
ward to the part to be anaesthetized. Novocaine and alypin have the 

VI-7 97 



98 THE DISEASES OF CHILDREN 

advantage of being non-toxic. This method is particularly suitable in 
anaesthesia of the tympanic membrane if the epidermal layer of the 
latter is intact, also for short operations and paracentesis. 

The anaesthetic effect of cocaine or its substitutes may be enhanced 
by electrolysis, with the anode in the external auditory canal. Insertion 
of a cotton plug saturated with adrenalin will not only insure ideal 
anaemia, but also deaden the pain, in some cases inducing complete 
anaesthesia. All the remedies mentioned are allowed to remain in the 
duct for 10-15 minutes. For the middle-ear spaces the instillation 
method is not suitable. 

Insufflation of powders (novocaine, alypin, anaesthesin, cycloform) 
can be recommended for absorption of granulations. The traumatic 
pain following endotympanal operations may be easily overcome by 
insufflation of anaesthesin. 

Satisfactory, complete, and long-lasting anaesthesia of the middle 
ear can only be accomplished by injection of 1 per cent, novocaine or 
alypin solutions, or Schleich's solution "I" (cocaini hydrochlorici 0.2, 
morphini hydrochlorici 0.02, acidi carbolici gtt. v, aquae destill. ad. 100). 
The solution is heated to body temperature shortly before use, and 5 
drops of adrenalin solution are added to 1 c.c. The most suitable syringe 
is Neumann's and the injection is made subperiosteal^ at the union of 
the cartilaginous and osseous parts of the duct. The upper wall of the 
duct is injected to anaesthetize the upper tympanic cavity, the postero- 
superior wall for the antrum, the basal wall for the hypotympanum, and 
the anterior wall for the tympanic end of the tube. The injection is made 
slowly and with little pressure, so as to prevent tearing the integument. 
A cotton plug saturated with the anaesthetizing fluid (preferably 20 
per cent, novocaine or alypin) is inserted after the injection, and the 
patient allowed to rest for 10 to 15 minutes on the healthy ear. 

In this way complete anaesthesia and anaemia of the middle ear are 
attained, which will last for about one-half hour. The Freiburg Ear 
Clinic recommends injections of a few drops of a 5-10 per cent, cocaine 
and adrenalin solution into the tympanic cavity to anaesthetize the 
tympanic membrane for paracentesis. Bernd recommends a thin, 
graded record syringe with a very fine platino-iridium needle. For 
removal of polypi, Frey recommends injection of Schleich's solution. 

Many operators prefer to use ethyl chloride as a general anaesthetic, 
especially in children. Fortunately, the young are quickly anaesthetized, 
and as they rapidly recover from the effects, it is the best anaesthetic 
for short operations. A thin towel or a chloroform mask is held over the 
patient's face, and the spray striking the mask is quickly vaporized. 
The patient is in the analgesic stage before completely anaesthetized so 
that a myringotomy may be performed with deliberation and ease, not 
possible under local anaesthesia, especially in an over-wrought patient. 



VIII. DISEASES OF THE CONCHA AND THE EXTERNAL 
AUDITORY MEATUS 

I. CONGENITAL ANOMALIES OF DEVELOPMENT OF THE CONCHA AND THE 
EXTERNAL AUDITORY MEATUS 

Slight deviations from the normal form and size of the concha and 
auditory meatus are very common. They include faulty or arrested 
development of the borders and end-parts of the auricle (tragus, helix, 
lobe), abnormal excrescences (Darwin's point, Macacus point), and the 
abnormal development of the concha itself (supernumerary crus anthel- 
icis, flat or unusually small cymba conchse, absence of antitragus, colo- 

Fig. 52. 




Coloboma of the concha with asymmetry of the skull and micrognathia (smallness of the jaws) in a twelve- 
year-old girl. 

boma (Figs. 52 and 52a). In macrotia the concha is enlarged in all its 
parts, the cartilage being unusually broad (Fig. 54), the fossa navicularis 
unusually deep, and the posterior wall of the cartilaginous auditory 
meatus unusually long. 

The consequence of these deformities is that in macrotia the concha 
is laterally deflected, and the anterior aspect is far more disturbing from 
a cosmetic point of view than the lateral aspect (Fig. 53). This con- 
dition occurs much oftener bilaterally than unilaterally, both concha? 
being usually enlarged to the same extent and in the same form. 

90 



100 



THE DISEASES OF CHILDREN 



Fig. 52a. 




Anterior aspect 



se shown in Fiy 



Treatment. — The patients' wish is to be freed from the disfigure- 
ment of pronounced macrotia, as it is often the cause of being teased in 

school, and sometimes in- 
terferes with their future 
career. The treatment con- 
sists in the surgical reduc- 
tion of the concha and those 
parts which are most prom- 
inent in the anterior aspect, 
the latter being the most dis- 
figuring. This refers par- 
ticularly to the abnormally 
enlarged lobes, the lateral 
surface of which is dis- 
placed forward (Fig. 53). 
It is trimmed down until its 
anterior aspect is normal. 
The reduction of the concha 
itself is best accomplished 
by extirpation of falciform 
pieces of integumental carti- 
lage and subsequent primary suture. Parts of the free border of the helix, 
if over-developed, can often be resected with excellent cosmetic results. 

In CONGENITAL MI- 
CROTIA the concha is only 
rudimentary, owing to 
defective development of 
the auricular cartilage. 
In most cases of microtia 
there is also atresia of the 
external auditory canal. 
The entire picture is one 
of arrested development, 
primarily due to circum- 
scribed adhesions of the 
amnion to the cranial 
epidermis in the auricular 
region, which occurs as 
early as the 4th to 8th 
embryonal week. At this 
period the free fold of the 
ear normally develops from fusion of the posterior and superior auricular 
prominences, while in cases of malformation the fold is either not developed 



Fig. 53 




Macrotia with disfiguring enlargement of the lobe. Boy fourteen 
years old. Cured by plastic operation. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 101 



Fig. 54. 



at all or it is convoluted forward and downward instead of spreading 
backward and upward. 

The extent of microtia is very variable, ranging from arrested de- 
velopment of certain parts to complete absence of the concha. In the 
latter case the concha is merely in- 
dicated by shapeless appendages of 
skin and fatty tissue. 

Congenital appendages (Figs. 
55, 58, 59) in the auricular region 
and pre-auricular fistulse (Fig. 56) 
are not very rare, particularly in the 
parotid region and auriculo-oral 
line, while appendages at the free 
parts of the ear itself are less 
common. Thus, falciform append- 
ages of skin and cartilage are only 
exceptionally observed at the helix in Macrotia with accessory tragus - Boy three weeks old - 
the region of Darwin's point, the disfigurement being usually bilateral. 
In making a differential diagnosis, it should be noted that skin 

tubercles in the auricular region 
in children may be mistaken for 
auricular appendages (Fig. 115). 
Treatment. — Auroplastic op- 
erations are only applicable in 
cases where the cartilage has 




Fig. 55. 






Fig. 56. 




k - ,; '^m 


I* 


- 

'^..■■—fjt ji 



Macrotia with multiple pre-auricular appendages. (Left 
side of Fig. 58.) Boy one year old. 



Macrotia with micrognathia and multiple pre-au- 
ricular fistula; in boy three months old. 



developed to a sufficient extent, rendering the use of pediculated skin 
flaps possible from the direct vicinity of the ear, particularly from 
the planum mastoideum, for the enlargement of the ear fold, for- 



102 



THE DISEASES OF CHILDREN 



mation of a helix, etc. Paraffin injections are in some cases fairly 
successful. Before injecting paraffin, a test injection is made with 
Schleich's solution I, to show the result to be expected, and, if sat- 
isfactory, small quantities of paraffin are injected at various sittings. 
Following Gersuny's instructions, I always use ung. paraffini, which is 
of ointment consistency at room temperature. 

In supplementing the cosmetic procedure by surgical removal of 
the auricular appendages, great caution should be exercised, for the 
resulting cicatrix in individuals with a tendency to callous scar-formation 
may be more disfiguring than the original condition. Plastic operations 
should not be undertaken before the 6th to 8th year, of age. 

Protheses may be resorted to in considerable deformity of the 
concha. There are excellent soft rubber concha protheses on the market 
which are fastened with wax to the auricular rudiment. In the majority 
of cases, however, patients prefer hiding the defect by the hair. 

2. CONGENITAL ATRESIA OF THE EXTERNAL AUDITORY CANAL 

Congenital occlusion of the external auditory meatus is nearly 
always associated with congenital deformity of the external meatus, 
and is usually a part manifestation of a more or less important malfor- 
mation of the external and medial ear. 

Anatomy. — Congenital atresia develops as early as the second 
embryonal month, when the development of the tympanum in the 
mesoderm surrounding the capsule of the labyrinth normally sets in. If 

the rudimentary tympanum fails 
to develop, the immediate conse- 
quence is the close proximity of 
the submaxillary articulation to 
the pars mastoidea. The normal 
external meatus also fails to de- 
velop in these cases, and the skin 
at this place is either smooth or 
forms a short blind fossula from a 
few mm. to 1 cm. long. This de- 
formity is usually associated with 

Congenital atresia of the left external auditory duct, with irregularity of the COncha, 

rudimentary development of the concha. ^te~ ~" J » 

which may be either entirely 
missing or replaced by several small shapeless appendages. The carti- 
lage is completely absent in some cases, while in others it is more or less 
rudimentary, serving as a support to the misshapen concha (Figs. 57, 58). 
Cases of congenital atresia with but slight deformity of the concha are 
rare (Fig. 59) . Examination of the temporal bone will usually show a 
greatly enlarged pneumatic mastoid process in close proximity to the fossa 
articularis of the submaxillary bone. 



Fig. 57. 




DISEASES OF THE CONCHA AND EXTERNAL MEATUS 103 

There are in all cases characteristic changes of the middle ear, the 
lateral wall consisting of a compact osseous plate. The Eustachian tube 
is present in the majority of cases; in a smaller number, in which there 
is atresia of the tube, the musculature of the soft palate is imperfectly 
developed at the side of the deformity. The tympanic cavity is small, 
stenosed from osteophytes, becoming narrower toward the tube, and 
giving the impression of the osseous tube being continued much further 
into the tympanic cavity than normal. The osseous tube usually ex- 
tends backward and outward to the corner of the cochlear window. 
The antrum is small. The middle wall of the tympanic cavity is in 

Fig. 58. 




Congenital atresia of the external auditory duct with microtia, the cartilage, however, being well 
developed. Auricular cone-shaped appendage in the auriculo-oral line; on the left side of this case (Fig. 55) 
there were macrotia and multiple auricular appendages. One-year-old boy. 

most cases of normal shape, but there are often osseous defects of the 
facial canal, osseous deposits and connective-tissue ligaments which 
may cause stenosis or occlusion of the corners of the vestibular and 
cochlear windows. The auricular vessels and the tympanic membrane 
are demonstrable in most cases, but always exhibit grave changes, the 
tympanic membrane, in the shape of an irregularly demarcated, flabby 
membrane, being more or less accumbent, but not adherent, to the 
lateral osseous covering-plate of the middle ear. The auricular vessels 
are small and coarse. The head of the malleus or the long crus of the 
incus is often deformed, both crura of the stapes plate are fused into 
each other, and this, together with the stapes rudiment, often recalls 
a similarity with the columella of birds. Sometimes the head of the 
malleus is jointed to the body of the incus, and the medial auricular 
ossicles consist of the long crus of the incus, which at both its ends is 
united by connective tissue with the lateral and the inner ossicle, re- 



104 THE DISEASES OF CHILDREN 

spectively. The entire chain of ossicles is enveloped in a dense net of 
connective tissue. The muscles of the middle ear, though present, show 
considerable degeneration, while the chorda tympani is missing. 

The contents of the middle ear more or less approach the normal 
in cases of slight deformity, while in higher degrees of malformation the 
rudimentary tympanic membrane may be completely absent, and, to- 
gether with it, malleus and incus, nothing but the rudimentary stapes 
FlG 59 being demonstrable. The ligaments and 

connective tissue of the middle ear show in 
all cases stronger development than normal. 
The internal ear is normally developed 
\\ in most cases of congenital atresia of the 
auditory canal and arrested development 
of the middle-ear spaces, participating but 
seldom in the malformation. Where, how- 
ever, the auricular deformity is associated 

b with severe congenital malformation of the 

entire body, — notably of the head, brain, 
heart, arterial blood-vessels, nose, eyes, or 
in twin monstrosities, such as syncephaly, 
synotia, anencephaly, — there is, aside from 
atresia, congenital malformation of the 
labyrinth and auditory nerves. These 
congenital atresia of the external audi- cases however, are of no clinical interest, 

tory duct with defective development of 

the helix ascendens (a) and a pre-auricular the fetUS being either Stillborn (uSUally 

appendage (6). (Natural size.) 1 \ • 

prematurely) or dying a few hours after 
birth, owing to the grave general defects of development. 

On the other hand, arrested development in congenital deafness is 
usually limited to the labyrinth, extensive or grave anomalies of the 
external or middle sections being but rarely observed. Extensive defects 
of development of all three auricular sections are a clinical rarity. 

Symptoms. — Congenital atresia of the external auditory meatus is 
associated with a cosmetic imperfection and derangement of hearing 
caused by the obstacle to conduction. 

Patients are generally not much concerned about the cosmetic im- 
perfection, as they can cover any such defect by the hair, while disfigur- 
ing scars at any other place, as for instance at the cheek or neck, are far 
more unpleasant. The hearing distance is reduced in all cases, amount- 
ing to 23^—27 feet C, which is but rarely exceeded, as the cause is not 
only atresia of the external meatus, but also such congenital changes of 
the middle ear as have been described. Relatively good hearing distance 
points to a good condition and slight congenital malformation of the 
middle ear and to a permeable tube capable of physiological function. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 105 

Youthful patients generally experience no subjective complaints, 
while adults mostly complain of numbness in the head and a feeling of 
fulness in the ear. 

Preservation of the middle ear in congenital atresia and defective 
concha may be the cause of suppurative otitis media, outward escape 
of the pus being impossible and escape through the Eustachian tube 
into the throat being impeded by the inflammatory swelling and con- 
striction of the tube. This explains why the suppuration will spread to 
the mastoid process in a comparatively short time, perforating either 
outside through the periosteum or toward the dura into the cranial 
cavity, unless there is timely surgical aid. 

The functional test in congenital deformity of the concha shows all 
the signs of a grave obstacle to conduction. Labyrinth symptoms are 
either entirely absent or there is a moderately reduced perception of 
high sounds with a lowered upper sound-limit, all of which points to 
changes in Corti's organ at the level of the promontory and cochlear 
window (vestibular part of the cochlea). 

Treatment. — Congenital atresia of the auditory meatus can gen- 
erally be noticed at the time of birth. Parents will ask whether and to 
what extent the misshapen ear may be expected to hear, and the satis- 
factory reply may be given in nearly all cases that there will be positive 
though reduced hearing ability. 

The hearing distance may amount to 3-37 feet C. and 8-12 feet 
for the acoumeter, but may be materially improved by insufflation of 
air or catheterizing; many patients acquire improved hearing acuity 
through their perfectly normal or even prolonged bone-conduction. 
Several years ago I observed a boy of thirteen with bilateral congenital 
atresia whose hearing distance attained 7-10 feet C; by pressing the 
forehead against a wooden board, an open door for instance, he was 
able to hear at a distance of 30-40 feet C; indeed, merely touching 
him increased his hearing acuity. According to his statement, he could 
understand a person better by placing his hand on the shoulder or head 
of the person he was conversing with. 

Cosmetic improvement seems impossible, since the submaxillary 
articulation immediately continues the mastoid process, and the middle- 
ear spaces are laterally closed by a compact bony layer. It is impossible, 
therefore, to construct an artificial auditory canal, extending to the 
tympanic membrane, which would correspond to normal conditions in 
regard to position, length, and course. 

The hearing acuity may be surgically improved by antrotomy, 
provided the antrum can be kept open exteriorly by skin plastic. This 
operation should only be resorted to if there is a sufficiently large rudi- 
ment of the concha, bilateral atresia, and provided the preserved orifice 



106 THE DISEASES OF CHILDREN 

of the antrum is covered or surrounded by the rudiments of the concha. 
In unilateral atresia patients are usually satisfied with the functional use 
of the healthy ear. The plastic flaps are best taken from the skin of 
the mastoid. Improvement in these cases is quite perceptible and per- 
manent. I have carried out this operation in three cases of congenital 
atresia in which antrotomy was indicated by an ulcerative process of 
the mastoid. Considerable and permanent improvement resulted in 
all three cases. 

3. ACQUIRED DEFORMITY OF THE CONCHA AND EXTERNAL AUDITORY 
MEATUS; ACQUIRED POSITION ANOMALIES OF THE CONCHA 

All inflammatory affections of the concha, primarily involving the 
cartilage and perichondrium or spreading from the integument to the 
perichondrium, may heal, but leave a more or less extensive deformity 
of the concha behind. Similarly, all skin defects of the concha lead to 
a deformity of the latter if they terminate in a keloid. Acquired patho- 
logical constriction (stenosis, stricture) of the external duct and acquired 
occlusion of the meatus (atresia) can nearly always be traced etiologic- 
ally to deep circular ulcerations of the external duct which have persisted 
for a long time. Organic strictures of the auditory duct which develop 
in the course of chronic middle-ear suppurations also belong to this 
class. 

Inflammation of the concha and suppurative perichondritis are 
regarded as the principal causes of acquired deformity of the concha, 
while tuberculous and serous perichondritis and haematoma auriculare 
are less often responsible. Where the cartilage is not involved, the de- 
formity consists only in a scar which flattens the structure, the concavi- 
ties of the concha disappearing by being more or less filled up with thick 
cicatricial tissue. Or there may be one or more keloid tumors protrud- 
ing above the level of the concha, which are very disfiguring. Deform- 
ities occurring after corrosions of the concha can be primarily traced to 
perichondritis produced by trauma or to the keloid which developed 
in the healing process. Piercing the lobe for ear-rings may sometimes 
give rise to disfiguring keloids in little girls. 

Inflammatory involvement of the cartilage may lead to circum- 
scribed or diffuse necrosis, and auricular cartilage once destroyed will 
not be regenerated. The skin duplicature which is kept distended by 
the cartilage becomes flabby as the ear shrinks. This may lead to con- 
siderable deformity, in rare cases even to complete destruction of the 
concha, leaving merely a shapeless protuberance of thick, callous, 
cicatricial tissue invested with the epidermis of the concha (Fig. 60). 

The treatment of acquired deformity of the concha is only cos- 
metically important. Injections of thiosinamin or fibrolysin may give 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 107 

some degree of satisfaction and prevent subsequent calcification or 
ossification. Keloids which are well demarcated, protruding or crested, 
may be removed, the trauma being covered by Thiersch's flaps. In 
this way it is usually possible completely and permanently to remove 
these disfiguring protuberances. 

Paraffin injections are in many cases of acquired corrugation of 
the concha cosmetically fairly successful. The first step in this process 
is to make a tentative injection with Schleich's solution, in order to 
observe the cosmetic effect to be expected, and, if the contour is improved 

Fig. 60. 




Shrinking of the concha after suppurative perichondritis. 

and the free parts of the shrunken ear are enlarged backward and up- 
ward, the case is a suitable one for paraffin injection. This should be 
done very carefully at several sittings, using the smallest quantities 
(not exceeding X A-Yi c.c.) at one injection. 

This treatment is suitable in all cases of perichondritic corrugation 
of the concha in which the otherwise deformed cartilage is not bent 
laterally; otherwise paraffin injections will not be able to distend the 
parts backward and upward. In these unsuitable cases paraffin would 
simply distend the skin laterally so that the enlarged remnant of the 
concha would stand off from the head, or the paraffin deposit would 
form a lateral tumor-like protrusion. In lateral bending of the carti- 
lage, paraffin injections should, therefore, be entirely refrained from. 



108 THE DISEASES OF CHILDREN 

In many cases of deformity of the concha, corrosion of the auricular 
region causes a fiat fusion of the middle plane of the concha with the 
mastoid and temporal regions. This can be remedied by circumcising the 
concha and remobilizing the free part with the aid of pedunculated flaps. 
The skin of the mastoid region is preferably used for this purpose, or, 
should this be cicatrized, the skin of the upper neck or nape. The opera- 
tion is best done at several sittings. Using, as I am in the habit of 
doing, 3 right-angled flaps, the upper part of the concha is mobilized at 
the first sitting, the lower one at the second (formation of the freely 
movable lobe), and the medial part at the third. Adhesion of the 
operated parts is prevented by insertion of a double flap of epidermis. 

4. ACQUIRED ATRESIA OF THE EXTERNAL AUDITORY MEATUS 

Acquired atresia is either membranous or solid. The solid form may 
consist of connective tissue or bone, or both. 

Acquired atresia of the external meatus results from (1) trauma 
(cuts splitting the external meatus and severing the concha, fracture of 
the external duct, corrosions); (2) chronic ulceration of the external 
meatus; (3) croupous inflammation of the external meatus; (4) bone 
formation in the middle ear in the course or at the end of chronic suppu- 
ration of the middle ear; (5) tumors. 

Cuts completely splitting the external duct and severing the concha 
are rare. They are almost exclusively sabre cuts hitting the parotid 
region in a vertical direction. 

The weight of the concha causes the lobe to gravitate downward 
even though the wound has been sutured in time. In the healing process 
the severed outer end of the external duct will be located below the level 
of the medial one, with the result that the medial part will be occluded 
by the cicatricial mass externally and the lateral part internally. 

Atresia in these cases can only be prevented by making a gutta- 
percha cast of the healthy meatus and holding the severed parts in 
proper position with its aid. 

Fractures of the auditory meatus caused by great violence (kicks 
from a horse or other blunt blows) may likewise cause atresia while 
healing, by dislocation of the fractured parts. In slight dislocations the 
meatus may assume quite a peculiar shape. I observed a case in which 
the kick from a horse led to fracture of the parietal and temporal bones 
and external meatus. The otoscopic picture of the latter represented 
the figure 8, the upper ring of the figure being situated anterosuperiorly 
and the other postero-inf eriorly ; they communicated with each other. 
This shape was caused by the fractured parts of the osseous auditory 
duct having become dislocated and healed with callous exostotic emi- 
nences (Fig. 61). 




DISEASES OF THE CONCHA AND EXTERNAL MEATUS 109 

Atresia due to corrosions is caused by the corrosive agent penetrat- 
ing into the external meatus leading to complete or at least annular 
destruction of the integument. They are usually the result of assaults 
in which large quantities of the corrosive fluid (solution of potash, sul- 
phuric, carbolic, or nitric acid) are thrown against the ear at a short 
distance, so that a portion of it will find its way into the meatus. Self- 
inflicted injuries of this kind are rare. 

Local treatment, though immediately instituted, will usually be 
unable to prevent atresia, and the ulceration is favored by the middle- 
ear suppuration set up by the same trauma. 

In atresia caused by croupous inflammation or ulceration of the 
auditory duct, or by sequestration of the osseous duct, there is nearly 
always chronic, fetid, neglected suppuration of the middle ear, the stag- 
nation of the fetid pus in the external meatus leading 
to maceration of the investing epithelium and ulcer 
formation, especially in the region of the osseous por- 
tion of the duct. The more frequent course, however, 
is for atresia to develop with periodical arrest of the 
ulceration of the auditory duct, the middle-ear sup- 
puration continuing and occluding the external meatus conical exostosis of 
for several weeks or months. As soon as the pressure duotfoibw^frfcture 
of the secretion in the middle ear is strong enough or membrane noTmTi pamc 
a cholesteatoma presses against the occlusion, the latter ' 
will be perforated, allowing pus and cholesteatomatous matter to escape. 
This fistula may become permanent or be closed from time to time. There 
is, of course, the danger of a fresh perforation occurring toward the inte- 
rior of the cranium, involving the endocranium. This process explains 
cases of atresia in which, after a prolonged period of well being and entire 
cessation of the external ulceration, there occur sudden symptoms of 
intracranial complications. 

There are cases of radical operation in which the trauma heals 
with connective-tissue atresia of the middle ear, which may extend to 
the level of the former external meatus. 

Formation of osteophytes in the course of chronic suppuration of 
the middle ear may lead to osseous occlusion of the middle ear and 
osseous atresia of the external meatus if the integument of the osseous 
part of the duct has been previously destroyed. 

Tumors of the bones and cartilage, as well as sarcoma, may extend 
to the auditory canal, leading to its complete obliteration. In the first 
form of tumor we have to deal with very rare osteomata of the mastoid 
process, otherwise merely with tumors of the submaxillary articulation; 
in sarcoma, with tumors of the parotid (Fig. 113), of the middle ear, 
or of the superior maxilla. 



110 THE DISEASES OF CHILDREN 

Symptoms. — If atresia occurs at the level or in the vicinity of the 
external auditory meatus, the patient will feel the occlusion with his 
finger and is soon aware of the cosmetic injury arising from the absence 
of the orifice. In all other cases, the manifestations depend upon the 
condition of the middle ear prior to the occlusion. With a healthy 
middle ear, atresia causes a more or less important reduction of the 
hearing distance, sometimes a sensation of fulness in the ear. On the 
other hand, atresia occurring in the course of chronic suppuration of 
the middle ear may be without symptoms, as the hearing acuity is al- 
ready in juried to such an extent that any further exacerbation remains 
unnoticed. But in cases where suppuration of the middle ear persists 
behind the occlysion, patients will complain of regional pains, tinnitus, 
headache, sensation of heaviness in the head, and evacuation of pus 
through the Eustachian tube into the throat; besides, the pressure of 
the secretion may cause irritative manifestations of the labyrinth, such 
as spontaneous nystagmus, rotatory vertigo, equilibrial disturbance 
and vomiting. 

The diagnosis of atresia of the auditory meatus presents no diffi- 
culties, the otoscopic picture showing the fossular, epithelialized occlu- 
sion. Less experienced physicians may have some difficulty in dis- 
tinguishing membranous atresia from a cicatrized tympanic membrane, 
and for these the following guiding points will be helpful. In atresia 
the manubrium can be neither seen nor palpated, and, besides, the 
occlusion is nearer the eye than the normal tympanic membrane. Fur- 
thermore, the entire normal tympanic membrane, with the exception 
of its anterosuperior border, is demarcated by a straight, sharp line 
against the integument of the auditory canal. The wall of the latter 
and the tympanic membrane form an angle, one side of which has the" 
pink color of the skin, and the other side the pearl-gray color of the 
tympanic membrane. An angular transition of this kind of the integu- 
ment of the auditory duct is never found in atresia. In connective- 
tissue atresia the integument of the auditory canal fuses gradually with 
the membrane of the occlusion without forming a distinct angle, and 
the peripheral parts of the membrane generally admit of a distinc 
recognition of the color of the skin. Dubious cases can be decided by 
investigation with the probe and Siegle's speculum. 

Treatment. — The only method of completely and permanently 
removing acquired atresia of the auditory meatus consists in plastic 
operations which correspond to the various types used in the radical 
operation. Thus, the auditory duct will be mobilized from the retro- 
auricular skin flap, severing the blind end of the duct with the scalpel. 
This creates the type of entirely normal conditions, the only difference 
being that the duct will be much shorter than normal if the atresia is 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 111 

close to the orifice. The simplest and best method is Koerner's or Siben- 
mann's plastic operation with tongue-shaped flaps. The skin flaps are 
thinned out as much as possible and fixed by catgut sutures. In simul- 
taneous suppuration of the middle ear, the radical operation is, of course, 
combined with that for atresia. When the middle ear is healed, subse- 
quent formation of cicatrical strictures of the external meatus should be 
prevented by resecting the corticalis up to a few mm. in the posterior 
osseous wall, the traumatic surface of the bone offering favorable con- 
ditions for rapid junction of the plastic flaps. 

As a rule, the plastic cuts are made up to the orifice of the auditory 
duct, except when atresia is a sequel to traumatic splitting of the ex- 
ternal meatus and gravitation of the lateral part of the duct ; in that case 
the incisions should be made backward and upward into the cymba 
conchse. It is impossible in these cases to return the concha from its 
abnormally deep adhesions to the normal position, and we must be con- 
tent with directing the new auditory duct to the correct upward position, 
which is effected by enlarging the normal auditory meatus backward 
and upward to an extent which will enable us at least to survey the 
tympanic membrane from the upper part of the auditory canal in the 
otoscopic picture. 

All other surgical methods recommended for atresia either fait from 
the beginning or will not prevent recurrence of the condition. Even in 
cases of membranous atresia the mere removal of the occluding membrane 
will not be permanently successful, as the subsequent cicatricial tissue 
invariably shows a tendency to recrudescence, so that re-formation of 
the atresia would be unavoidable. Furthermore, extirpation of fibrous 
atresia is not without danger, as injury to adjacent parts is extremely 
liable to occur, paving the way to traumatic meningitis or ulceration of 
the labyrinth (luxation of the stapes !) . 

5. TRAUMATIC INJURIES OF THE CONCHA AND THE EXTERNAL AUDITORY 
MEATUS, INCLUDING CUTS AND BITES 

Contusions of the concha lead to skin hemorrhages, sometimes to 
extensive effusions of blood, at the lateral surface between the cartilage 
and perichondrium (hsematoma auriculare). Generally speaking, hsem- 
atoma is rare in children and is nearly always due to trauma. Haemato- 
mata are particularly liable to occur from violent blows, rarely from 
pulling or pressing. 

The symptomatic picture of congelation of the concha corresponds 
to an acute dermatitis spreading to the perichondrium and is often 
associated with considerable swelling. Continued exposure to cold may 
lead to more or less extensive necrosis of the auricular cartilage. 

Burns and corrosions of the concha present different clinical find- 



112 



THE DISEASES OF CHILDREN 



Fig. 62. 



ings according to the degree of the injury and the time of exposure. 
The slightest degree consists in hypersemia and cedema of the skin of 
the concha, perichondrium and cartilage remaining intact. In serious 
cases the integument is destroyed, usually leading to acute perichon- 
dritis within a few days, with the ulcerative inflammation unavoidably 
spreading to the cartilage. 

Burning or corrosion of the ear and vicinity lead to extensive sup- 
erficial ulceration, the centre of which is the denuded, inflamed concha. 
The elasticity of the cartilage has been destroyed; the concha recedes 
almost completely against the cranium after the auditory duct has be- 
come ulcerative, which is usually the case. 

In anaemic children suffering from a serious disease, pressure necro- 
sis of the cartilage may develop (Fig. 62). This is almost without ex- 
ception a sign of negligence, and occurs from allowing the patients to 

lie too long on one side, the head exercising 
continued pressure on the kinked and com- 
pressed concha. Ulceration can be avoided by 
cleanliness (bathing the ear with benzine and 
applying borvaseline to the inflamed places). 
Care should be taken that the concha is always 
flat, that the head rests on a soft pillow, and 
that the children should not remain longer than 
an hour in the same position. 

Symptoms. — The local pain is but rarely 
extreme and subsides rapidly even after serious 
injury. The temperature is normal or slightly 
elevated. According to the stage and degree of 
the injury, the concha is more or less swollen, 
the skin hypersemic, raised by vesicles, or ulcer- 
ating. When extensive ulceration has already 
taken place, there will be all the signs of ulcera- 
tive perichondritis with abscess or ulcer formation. 

The course of traumatic injury to the concha is entirely dependent 
upon whether the perichondrium and auricular cartilage have been 
involved. If not, the cosmetic result will be completely satisfactory. 
Involvement of the perichondrium, however, will probably lead to thick- 
ening of the concha. Partial destruction of the cartilage will nearly 
always cause shrinking, since the destroyed parts will not be renovated 
by cartilage, but by cicatricial tissue, the gradual shrinking of which 
cannot be prevented. In corrosion of the concha and the lateral cranial 
skin, superficial cicatricial adhesions between concha and cranium will 
develop, unless early cutaneous transplantation is resorted to. 

Injury to the concha from cutting instruments, especially sabre 




Pressure necrosis of the auricular 
cartilage in a child three years old, 
with advanced pulmonary and gland- 
ular tuberculosis. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 113 

cuts, is very rare in childhood. Bites from dogs, entirely perforating 
the concha, including both the epidermal layer and cartilage, are more 
frequent. 

The prognosis of cuts is cosmetically favorable, unless the injury is 
complicated by an ulcerative infection. Owing to the abundant anas- 
tomosis of blood-vessels and the excellent blood supply of the entire 
concha, the severed parts will grow together, even if only a narrow 
bridge is left to connect them and the concha is completely cut through. 
I have seen several such cases with excellent cosmetic results. 

The treatment of tears and cuts consists in carefully cleansing the 
wound with a bichloride solution and correctly approximating the 
severed parts with a few cutaneous sutures; these should not go beyond 
the skin, so that perichondrium and cartilage will not be touched. Even 
if the concha has been completely severed, there is still a chance of 
success if correct apposition and fixation have been attended to at an 
early stage. 

6. SEROUS PERICHONDRITIS 

In serous perichondritis there is a clear, yellow, serous or sero- 
mucous exudate between the lateral surface of the cartilage and the 
skin of the cartilage. The favorite seats of the inflammation are the 
fossa of the helix and the triangular fossa. Accumulations of the exudate 
in the cymba conchse are rare, while in the basal and medial parts of the 
concha perichondritis has never been observed. The inflammation 
occurs without any known cause or after slight trauma. Constitutional 
anomalies, such as anaemia and affections of the blood and blood-vessels, 
and chronic infectious diseases, such as tuberculosis and syphilis, seem 
to favor the occurrence of serous perichondritis. In patients suffering 
from serious illness, the affection may occur from the head lying too 
long upon the kinked concha, although circumscribed necrosis would 
be a more frequent consequence. 

In the majority of cases the affection is unilateral, although its 
bilateral occurrence is by no means rare. It occurs principally toward 
the end of winter and is more frequent in northern than in southern 
climes, so that apparently cold weather favors its occurrence. Bac- 
teriological examination reveals either no micro-organisms at all or 
only degenerated ones. 

Symptoms. — There is neither pain nor elevation of temperature, 
as a rule, but in the initial stage there may be an unpleasant sensation 
of tension in the ear. Moderate elevation of temperature in the initial 
stage has been observed in some exceptional cases. 

The diagnosis is made from the characteristic onset and further 

course of the affection. The only question to decide is whether there 
\i — 8 



114 THE DISEASES OF CHILDREN 

is an accumulation of serous, sanguineous, or purulent exudate in the 
region of the swelling. This is determined by examining the diaphanous 
properties of the concha by means of a reversed monaural stethoscope. 
The concha is pushed away from the head and held against a light; in 
serous perichondritis it appears light red, in hsematoma (accumulated 
blood) dark red, and in accumulation of pus the field of vision will be 
black. 

The skin of the concha remains completely unchanged, even with 
extensive and long-persisting exudation: a symptom which allows of 
differentiation between serous and purulent or phlegmonous perichon- 
dritis. 

Treatment. — The best cosmetic result is attained by conservative 
treatment, consisting in light massage with an iodine ointment or with 
Crede's silver ointment. Compresses saturated with absolute alcohol 
are applied overnight, the auditory meatus having first been closed by a 
firm cotton plug and a small strip of Billroth's gauze or gutta-percha. 
Under this treatment the exudate will be resorbed in the course of 4-8 
weeks, leading in some cases to normal restoration of the concha and in 
others to a slight, cosmetically unimportant thickening of the carti- 
laginous skin in the region of the serous exudate. 

During the last few years I have completely abandoned the surgical 
treatment of serous perichondritis. Aspiration and subsequent appli- 
cation of compresses have no effect, as within a short time, sometimes 
within a few hours, a new exudate will accumulate equal dimensions. 
Evacuation of the exudate with subsequent injection of irritating fluids 
(iodine solution, weak formalin solution, chromic acid solution) are to 
be deprecated, giving rise as they do to an apprehension of cartilaginous 
necrosis and transformation of the serous into purulent perichondritis 
with abscess formation. Incision and tamponade of the exuding cavity 
with iodoform gauze have been recommended; but the healing process 
under this treatment is very slow, and the patient is sometimes compelled 
to wear a bandage over the ear for several weeks, and the final outcome 
always shows perichondritic thickening with a callous cicatrix which is 
often of a very disfiguring character. 

7. PHLEGMONOUS PERICHONDRITIS. ACUTE PURULENT PERICHONDRITIS 

Acute purulent inflammation of the perichondrium and connective 
tissue of the concha occurs exclusively from infection with bacterial 
pyogenic factors. The bacillus pyocyaneus is found in the great majority 
of cases, although infection with the various kinds of streptococci, 
staphylococci and diplococci pneumoniae is by no means rare. In ex- 
ceptional cases, perichondritis may be caused by bacterium coli or 
proteus. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 115 

The conchial inflammation usually develops from a traumatic 
superficial injury to the concha. An inflammation may also develop 
from secondary infection after operation on the mastoid. 

Symptoms. — The phlegmonous inflammation sets in with a diffuse 
swelling and reddening of the concha. The contour of the lateral sur- 
face becomes gradually obliterated. The concha continually increases 
in size and weight and may attain to twice its normal conditions. The 
skin becomes fissured, and finally desquamates in crusts or sclerotic, 
moist, epidermal rags. As a rule, pains only occur at the beginning of 
the affection, while medium elevation of temperature will persist for 
one or two weeks. Patients also complain of numbness of the head, 
heaviness of the entire auricular region, and lassitude. 

Course. — In a small number of cases, phlegmonous inflammation 
of the concha will heal by spontaneous resorption of the inflammatory 
exudate without abscess formation; but in the majority of cases an 
abscess will form, in the course of the second week or later, at the lateral 
surface of the concha, in the area of the fossa helicis or cymba conchae, 
and then purulent perichondritis will mark the end of the phlegmonous 
inflammation of the concha. Perichondritic abscesses of the medial 
surface of the concha are rare. The phlegmonous inflammation may 
also spread from the concha to the membranous part of the auditory 
duct, or a diffuse swelling may extend to the region of the upper neck 
and parotis, less often to the mastoid region. 

The diagnosis is usually easy if the climax of the affection has been 
reached. In the initial stage it may be difficult to differentiate between 
it and erysipelas of the concha and herpes zoster. Besides, erysipelas is 
in many cases associated with phlegmonous inflammation of the concha. 

In a painless and afebrile course of an apparent phlegmonous peri- 
chondritis there is always the suspicion of tuberculous perichondritis. 
In the latter affection there are one or more long fistulous canals which 
end superficially at the medial conchial surface near the lobe. In the 
absence of any such fistulse the painlessness of the initial stage, normal 
temperature, and protracted course point to the tuberculous nature of 
the process. 

Treatment. — In the initial stage of the inflammation the surface 
is covered with sterile borvaseline, and a moist compression applied with 
warm acetic alumina or 1 per cent, lysol. Above this a warm or cold 
compress (thermophore, ice-bag) is applied, according to the patient's 
liking. If there are signs of a spontaneous involution without abscess 
formation, 90 per cent, alcohol or salicyl alcohol compresses are applied, 
which have often a remarkably rapid favorable effect. An abscess 
should not be incised until it is distinctly demarcated .and there is fluc- 
tuation in the entire surrounding region. Early incision is not to be 



116 THE DISEASES OF CHILDREN 

recommended because, in spite of the incision, other ulcerations may form 
and require renewed incisions. Care should be taken to make the in- 
cision from the medial plane of the concha, in order to prevent any dis- 
figurement of the conchial contour by an unavoidable scar at the lateral 
surface. The incision is invariably made at the medial surface when 
the abscess is located there, but also in lateral abscesses which have 
reached considerable dimensions and led at least at one place to perfora- 
tion of the necrotic auricular cartilage. The abscess can then be drained 
through the opening to the medial surface of the concha. 

Should incision at the lateral conchial surface be necessary, it 
should be made to terminate anteriorly in a concave shape for cosmetic 
reasons, as the scars thereby occasioned will best fit in with the normal 
lines of the concha. Furthermore, it is advisable to incise at a concave 
place of the concha, so that the convex parts of the lateral plane may 
remain topographically unchanged after healing. 

Result. — Any case of phlegmonous or purulent perichondritis may 
heal with a permanent deformity of the concha, which, if slight, will 
consist of a diffuse thickening of the concha resulting from the perma- 
nent thickening of the perichondrium, or there may be flattening of the 
lateral conchial surface or perpetual scars after incisions. 

In necrosis of large parts of the perichondrium, shrinking of the 
concha after healing is unavoidable, and, in unfavorable cases with a 
grave course, all that may remain of the concha is a shapeless fibrous 
appendage covered with skin. 

The patient, or those in charge of him, should always be informed 
at an early period, preferably at the time of making the diagnosis, that 
a permanent disfigurement may be expected after the inflammation 
has subsided; otherwise there may be reproaches later on, and possibly 
legal proceedings. 

8. FOREIGN BODIES IN THE EXTERNAL AUDITORY DUCT 

In most cases of foreign bodies in the ear, children have inserted 
them while playing, especially if they are in the habit of boring their 
fingers into the meatus because of chronic itching or eczema. It is 
comparatively seldom that one child stuffs foreign bodies into the ear 
of another. The objects vary considerably, and may consist of cherry- 
stones, coffee-beans, beans, peas, small pieces of wood, pearls, bits of 
lead-pencil, plant-seeds, little stones, pieces of garlic, cotton, etc. Living 
fly larvae (musca or lucilia macellaria) and fungi (aspergillus, ascophora, 
and mucor mucedo) are sometimes found in the meatus. Small beetles, 
fleas, bugs, ear-worms, may find their way into the ears of children 
sleeping in the open or in unclean beds. Small winged insects, even 
small butterflies, may similarly intrude while buzzing about. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 117 

The first clinical question is whether the foreign body is one which 
will remain unchanged or undergo secondary changes. Beans, for 
instance, may gradually desiccate in the ear, but may also swell or even 
germinate in the ear, especially if water has simultaneously penetrated. 
Garlic particles may lead to painless hyperaemia (corrosion) of the 
tympanic membrane. A second point of clinical importance is the posi- 
tion of the article. An object introduced by the patient himself, and 
upon which no unsuccessful attempt at extraction has been made, will 
usually remain in the membranous part of the auditory duct. If the 
article is specifically heavy (small stones), it may wander into the osseous 
part, but will never transgress the isthmus. Only such articles will be 
found beyond the isthmus which have been inserted by others, or upon 
which unsuccessful attempts at extraction have been made. 

Symptoms. — Articles which are not subject to secondary changes 
and are located in front of the isthmus may remain for a long time with- 
out giving rise to any symptoms. Children may forget the fact of their 
presence or omit to mention it; the articles will gradually be covered 
with cerumen, and may perhaps be found years afterward when a ceru- 
minous embolus is removed or the ear is examined for some other purpose. 

If the article occludes the auditory canal, it may form a considerable 
obstacle to sound-conduction and cause partial deafness, especially if 
there was an accumulation of cerumen which has been pushed forward 
against the tympanum. Impacted articles also occasion unpleasant 
tickling or pressure, and sometimes pain. The movement of living in- 
sects in the ear causes loud subjective noises. Articles impacted in the 
osseous part, in the isthmus, or in the deep parts of the external canal 
cause considerable pain; those which are subject to decomposition may 
lead to inflammation of the skin or of the entire canal. If the integument 
of the latter or the tympanic membrane has been injured, there will be 
bleeding from the ear, either immediately or in the course of a few days. 
Serious general manifestations and cerebral symptoms point to extensive 
injuries of the ear or of parts of the temporal bone adjacent to the cere- 
bral cavity. 

The most serious symptoms occur from unsuccessful attempts at 
extraction. Unsuitable instruments may cause extensive injuries, and 
every unsuccessful attempt will unfavorably change the position of 
the article, which is always pushed deeper into the ear, perhaps down 
into the middle ear. The use of an unclean instrument, such as a hair- 
pin, toothpick, ear-spoon, etc., may lead to serious suppuration of the 
middle ear and consequent decomposition of the foreign body, particles 
of which may find their way into the middle-ear spaces. In favorable 
cases, however, the article will be expelled together with the pus or be 
entirely destroyed by the latter. Living larvse of flies are found in the 



118 THE DISEASES OF CHILDREN 

external ear in many cases of neglected chronic suppurative otitis 
media, or fungi (otomycosis) in cases of eczema of the auditory canal or 
ceruminal emboli. 

The diagnosis of the foreign body does not, as a rule, cause any 
difficulty, especially as children are usually brought to the physician 
with the express statement that a foreign body has entered the ear. If 
the auditory canal has otherwise remained unchanged, there will be no 
difficulty in establishing the nature of the article with the otoscope. 
This, however, is not sufficient, and the article should be palpated and 
diagnosed with the sound. This is the more valuable when neither the 
patient nor his parents are able to state definitely what the nature of 
the article is. A swollen meatus should be gradually widened by the 
careful insertion of small specula until it is possible to inspect the article. 
Blood coagula preventing inspection should be removed with a 
cotton tip. 

The prognosis is favorable in all cases in which the foreign body 
has been introduced by the patient himself, where there is no inflam- 
matory reaction of the meatus, and where no unsuccessful attempts at 
extraction have been made. Statements in regard to the latter point 
are not always reliable, as those responsible for the attempts are apt to 
deny them. If the meatus is unchanged, and the child allows the exam- 
ination to proceed without objection or fear, it may be taken for granted 
that the article has so far remained untouched. Should the child object, 
show fear, or complain of pain in the external meatus, should fresh or 
coagulated blood be found there, then there can be no doubt that at- 
tempts at extraction have been made, and responsibility for the possible 
consequences should be declined, as the tympanic membrane might have 
been ruptured in those attempts, and, if the physician subsequently 
injects water to remove the article, an inflammation of the middle ear 
may be the result- 
In regard to hearing ability after the extraction, any statements 
made should be very guarded, since there is always a possibility of a 
previously existing affection of the ear. I am in the habit of confining 
myself to the statement, even in quite uncomplicated cases, that the 
child will be able to hear as well after the removal as before introduction 
of the article. It is a rare occurrence that chronic suppuration of the 
middle ear should have escaped the relatives, leading a child to stuff 
some article into his ear, but, if the physician has not given thought to 
this contingency, he may be held responsible for the suppuration when 
it reappears after the removal of the article. 

Treatment. — Articles located in the membranous portion of the 
auditory canal can be removed without difficulty by the injection of 
water. The syringe should hold 150-200 c.c. and be provided with a 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 119 

cannula from 2 to 3 mm. wide. The patient is directed to open his mouth, 
and the cannula is inserted into the auditory meatus so that the longi- 
tudinal axis of the syringe will point downward and inward. The concha 
is firmly pulled backward and upward, thereby stretching the auditory 
meatus. Impacted articles may likewise be removed with the syringe 
in many cases. If the article cannot be dislodged with the head in the 
ordinary position, supination with the head hanging down may facilitate 
successful removal. The water used should be sterilized and have a 
temperature of 100°-104° F. 

Syringing is contraindicated if the article to be removed lies with a 
concave surface toward the meatus, if the article is decomposed or has 
undergone secondary changes (germinating beans, decomposed parti- 
cles of garlic), or if the integument of the external meatus is inflamed 
and the auditory canal constricted. 

In these and all such cases in which the article cannot be dislodged 
with the syringe, its instrumental removal should be considered. For 
this purpose firmly grasping, serrated, geniculate forceps or blunt and 
pointed hooks are used (Fig. 63). Large and small forceps should be 
held in readiness. Any such article as can be picked up from the hand 

without danger of slipping can be removed with the 

«. i • r FlG - 63 - 

forceps, as for instance coffee-beans, pieces of bone or 

glass, intact pieces of garlic, paper, etc. If there has been 
a previous injection, the article should be carefully dried 
with cotton tips so as to prevent the forceps slipping. 
Round articles with smooth surfaces, such as little pebbles, 
cherry-stones, corn, etc., should not be touched with the 
forceps. These articles should be removed with the hook, 
should attempts with the syringe prove unavailing, blunt 
hooks being used for hard articles and pointed hooks for 
soft ones. The hook is inserted flat between the upper 
wall of the auditory canal and the foreign body, and then 
turned downward. Hard articles can then be brought 
out by careful gliding and rotating movements. For 
soft articles permitting the use of the hook, the instru- 
ment should be twisted by 90° while inserting it, the 
article being hooked while withdrawing it. It is then 
brought out with one traction of the hook. Pointed hook for 

° removal of foreign 

In order to determine the position of the hook from bodies. (Two-thirds 

.. i i i i /- i • i c natural size.) 

outside, the instrument should be fitted with a four- 
edged handle appropriately marked, so that the position of the handle 
will always indicate the position of the hook inside the ear. Superficially 
located articles at the entrance to the canal which cause no occlusion may 
be easily removed with a small oval spoon made of metal or hard rubber. 



120 THE DISEASES OF CHILDREN 

Instrumental removal of a foreign body is a piece of art which 
requires considerable manual dexterity. The assistance of a trained 
nurse is requisite to ensure absolute stability of the patient's head, as 
otherwise an unexpected movement may cause injuries to canal and 
membrane with the pointed hook. In restless children or in the presence 
of an inflammatory process of the external auditory canal it is advisable 
to induce inhalation anaesthesia. 

The removal of articles introduced with great force (projectiles, 
wood or glass splinters in explosions) and impacted in the osseous part 
of the canal may require operative interference. So do foreign bodies 
which have been firmly wedged for a long time deep in the osseous canal 
and beyond the isthmus. In these cases the osseous canal should be 
exposed by a retro-auricular cutaneous incision. Should this be un- 
successful, the posterosuperior wall of the auditory duct should be 
superficially removed with the chisel. This will widen the osseous canal 
and render the removal of the article possible. If the latter has pene- 
trated to the mastoid process or antrum, opening of the mastoid or 
antrotomy will be necessary. Should the membranous portion of the 
duct be intact, it is readjusted after the article has been removed, and 
packed with xeroform gauze. In cases of extensive injury or ulceration, 
plastic surgery should be resorted to in order to prevent cicatricial 
stricture or atresia. In most cases it will be sufficient to make a hori- 
zontal incision along the posterior wall of the auditory canal. In con- 
siderable injury to the canal, one of the plastic methods used in the 
radical operation should be selected. Ulcerative parts are removed with 
the scissors. The plastic flaps are kept in position by catgut sutures 
and tampons. 

Larvae or flies can be extracted with ear-forceps after instilling a 
few drops of volatile oil into the meatus (turpentine, origanum). They 
sometimes attach themselves with their suckers to the middle-ear mucosa 
or to granulations. Small insects are removed with the syringe or, 
should they be otoscopically visible, with the forceps. 

Iron articles can be removed with the powerful magnets used by 
oculists or with Hirschberg's electromagnet. 

After removal of the foreign body, the exact condition of the tym- 
panic membrane should be determined and recorded in writing. The 
auditory meatus is then closed by an antiseptic gauze strip. Should there 
be any apprehension of the ear being meddled with after operation 
(instillation of oil, etc.), an ear-bandage should be applied. It is also 
advisable at once to inform those in charge of the patient of the prog- 
nosis and to point out the possibility of middle-ear inflammation in the 
event of any injury to the tympanic membrane. 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 121 

9. OTITIS EXTERNA ECZEMATOSA (ECZEMA OF THE CONCHA AND EXTERNAL 

AUDITORY MEATUS) 

Eczema of the concha and the external meatus is of frequent occur- 
rence in childhood; it is a tormenting and sometimes very obstinate 
disease. Usually it is associated with eczema of the head or face and 
seldom occurs independently. In other cases, where the patient suffers 
from eczema at other parts of the body, especially the lids, anus, umbil- 
icus, olecranon, popliteal space, etc., the auditory meatus participates 
in the affection. Auricular eczema is either acute or chronic, according 
to the duration of the affection, and clinically we distinguish between 
vesicles, papules, moisture, scales, or crusts of eczema vesiculosum, 
papulosum, madidans, squamosum, crustosum, etc. 

Furthermore, otitis externa eczematosa develops from neglected 
infectious purulent diseases of the external ear or middle ear. Every 
case of auricular furuncule or middle-ear suppuration may finally lead 
to eczematosis of the external ear. Canals invested with very vulner- 
able thin integument rather tend to squamous eczema, while a thick 
integument with plenty of fat and sebaceous glands tends to eczema 
madidans. Artificial eczema of the external ear may occur from scratch- 
ing with hard, rough, or unclean articles to stop the itching. 

Toxic eczema is sometimes observed after the use of iodoform or 
isoform in the treatment of the ear. Again, thermic or chemical irrita- 
tion, arising from the use of volatile oils or strong-smelling substances, 
such as chloroform, camphor, Peru balsam, thymol, etc., may cause 
acute eczema of the external duct. 

Eczema may also be the result of trauma caused by careless or 
exaggerated tamponade of the external meatus and impacted foreign 
bodies which irritate the skin. Persistent maceration of the integument 
resulting from continuous instillations in otitis media or from the swelling 
of foreign bodies (germinating beans) may develop into acute, eczematous 
inflammation of the external auditory duct with stormy symptoms. 

Auricular eczema may also occur without any particular local 
cause in under-nourished, enfeebled individuals. This is liable to occur 
in rhachitis, chronic pulmonary tuberculosis, marasmus, anaemia, dia- 
betes and untreated syphilis. Dyspeptic children frequently suffer 
from eczema. Nutrition plays an important part in infancy, eczema 
being far oftener observed in artificially fed, atrophic infants than in 
well-nourished, breast-fed children, although over-nutrition may like- 
wise be a causative factor. Intertrigo, which is usually found where 
two skin surfaces are in contact, may occur behind the ear along the 
border of insertion of the concha, especially in very fat infants and 
children. 

Symptoms. — Otoscopic examination will usually reveal a medium 



122 THE DISEASES OF CHILDREN 

degree of swelling of the skin of the external ear and an accumulation 
of crusts which may completely cover the tympanum. This swelling 
may in moist eczema lead to complete occlusion of the lumen. Acute 
eczema of the concha often sets in with considerable oedema and hyper- 
emia, vesicles and papules with serous or purulent contents, resembling 
herpes. In chronic squamous eczema the integument of the auditory 
duct is extremely thin, atrophic, easily vulnerable, and covered with a 
layer of brittle crusts which are easily detached. Slight mechanical 
irritation is sufficient to cause a profuse lymphatic secretion in chronic 
eczema of the external meatus. Skin irritations of this kind consist in 
rubbing or scratching with hard objects, syringing, or careless wiping 
with cotton tips. 

Eczema of the external auditory duct has a peculiar tendency to 
relapse. The duct remains normal for some time, but gradually there 
is an accumulation of crusts and scales, which eventually exercise pres- 
sure on the integument and change without any further cause the squa- 
mous into the moist form. The latter then very rapidly spreads to the 
surrounding skin of the meatus, which becomes brittle, forming furrows 
and crusts, easily bleeding fissures in cold weather, and acute eczema 
madidans of the face and head. Relapses of the latter form are espe- 
cially to be apprehended in exostoses of the external duct. 

The epidermal layer of the tympanic membrane is unchanged in 
most cases of eczema of the ear; in some there is swelling, maceration, 
or desquamation of the epidermis, with injection of the vessels of the 
manubrium. Application of irritative remedies may also lead to in- 
flammatory manifestations of the tympanic membrane in the form of 
reddening, swelling, and suppuration; the glands in the auricular region 
are generally enlarged and sometimes painful. The upper superficial 
cervical lymph-glands are particularly involved, likewise those of the 
inner surface of the submaxillary bone, whereas the mastoid gland is 
relatively rarely enlarged. 

Itching of the skin is a very troublesome symptom accompanying 
eczema. It arrests all desire to work, causes headache and lassitude, 
and diminishes attention. Thus, children with itching eczema of the 
auditory canal are often unable to attend to their lessons and are con- 
sequently considered inattentive or incapable of concentration. Various 
nervous manifestations may be caused in the course of time, such as 
twitching in the region of the facial and cervical musculature, psychic 
excitability, and, in rare cases, epileptic convulsions. In the chronic 
form there is often a thin, abundant, yellow or brownish-yellow, highly 
malodorous secretion. 

The functional test reveals a slight obstacle to sound-conduction, 
if the osseous part is permeable and the lateral tympanic membrane is 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 123 

not directly covered with crusts. Should, however, the entire duct, or 
even its deep parts, be covered with crusts, the hearing acuity will be 
considerably reduced ; eczema madidans has the same effect if the secre- 
tion fills the osseous part and covers the tympanic membrane. 

The diagnosis offers no difficulties. The differential diagnosis 
should take into consideration acute, phlegmonous, or purulent peri- 
chondritis, herpes, lupus, and erysipelas. Acute eczema sets in with 
painless swelling and reddening of the skin, and, with the exception of 
the itching, there are no subjective complaints. Phlegmonous or pur- 
ulent perichondritis, however, causes pains which will not subside until 
the abscess is in the process of formation, but in that stage no confusion 
with eczema is possible any longer. In herpes, vesiculation is associated 
with continuous, severe pains. As for lupus, see p. 390. In erysipelas 
of the concha there is always much fever, while the temperature in eczema 
is normal except in pronounced eczema madidans, which is associated 
with considerable oedema of the concha and lymphatic glands and with 
slight elevation of the temperature. Besides, thorough and repeated 
examination will serve to establish the characteristic demarcation and 
migration of erysipelas. 

Several days' observation may sometimes be necessary to decide 
the question as to whether eczema of the external duct is associated 
with an affection of the middle ear. In doubtful cases of this kind the 
external auditory duct is carefully cleansed and sterile gauze strips are 
inserted and pushed forward into the osseous part. In profuse secretion 
they are renewed every hour, otherwise 2-4 times daily. In this way it 
will be possible to survey and examine the tympanic membrane, even in 
the most obstinate cases, on the second or third day. 

A valuable aid for clearing up the differential diagnosis is the hear- 
ing acuity after cleansing the external duct and freeing the tympanic 
membrane from crusts or scales. A thin speculum is inserted to keep 
the duct permeable. Normal or slightly reduced acuity under these 
conditions would exclude a simultaneous affection of the middle ear, 
while considerable reduction of the acuity (to from 7-13 feet C.) would 
indicate its involvement. 

Treatment. — In the presence of a demonstrable special cause, 
therapy and treatment should be adapted to the conditions, and the 
removal of the causative factor will often cause the eczema to disappear. 
Thus, in middle-ear suppurations care should be taken to provide for 
adequate drainage. In chronic suppuration of the middle ear, with 
caries of the temporal bone, radical operation is required to arrest the 
eczema. Should eczema develop in the course of middle-ear treatment, 
it would point to want of cleanliness or to the employment of unsuitable 
antiseptics which are not tolerated. Such an eczema will disappear 



124 THE DISEASES OF CHILDREN 

with sufficient attention to antiseptic rules and avoidance of strongly 
irritating agents (iodoform, isoform). 

Eczema of the ear as part manifestation of general eczema or con- 
stitutional affection will only yield to local treatment in conjunction 
Avith general treatment. 

In acute eczema madidans with considerable oedema of the concha 
or auditory duct, compresses and insertion of acetic alumina (1 : 6) or 
1 per cent, lysol solution render good service, or in some cases compresses 
saturated with 95 per cent, alcohol, provided the latter is well borne and 
does not give rise to exacerbation of the subjective complaints. These 
compresses, however, are not allowed to remain in situ for more than a 
few hours. After removal, the ear is kept free for a few hours, followed 
by application of acetic alumina compresses. Alcohol insertions are not 
to be recommended in eczema of the auditory duct. Irrigations of the 
duct with water or washing the ear are contraindicated. 

Eczema exhibiting slight moisture or scales should be treated with 
ointments in the form of compresses or inserted into the external duct. 
It is advisable to keep the ointment in a tube and squirt about 2-3 cm. 
on a sterile gauze strip. The ointment is enveloped in the gauze and 
inserted deep into the external duct. The advantage of this arrangement 
is that all crusts and scabs which the action of the ointment has loosened 
will adhere to the gauze and be removed with it on withdrawal. 

The ointments to be recommended for eczema of the external audi- 
tory canal are boric (2 per cent.), zinc (2-5 per cent.), epicarin (2-5 per 
cent.), and resorcin (1 per cent.). As a base, ung. simplex, lanolin, or 
ung. emolliens is better than vaseline. Should there be considerable 
itching, 1-2 per cent, precipitate ointment is often very effective. 

In simultaneous local irritation or furunculosis of the external duct 
an admixture of ansesthesin or cycloform is often advantageous. 

The use of ung. diachylon simplex (sine ol. lavand. parat.) demands 
the greatest caution, as the unavoidable irritation of this preparation 
often leads to acute swelling with considerable pain. Squamous eczema 
calls for ung. emolliens; in chronic cases careful touching up with 3^-5 
per cent, silver nitrate and ear-baths with 1 per cent, potassa sulphurata 
are often attended with good results. Carbolin solutions or ointments 
(zinc oxide 4.0, carbolic acid 0.6, white vaseline 30.0), boralcohol, or 
tinctura rusci are tolerated only in rare cases. 

Applications of desiccated powders (dry tampons of rice powder, 
calomel powder, vioform or airol powder) usually have but a temporary 
effect in lessening the subjective complaints. The exaggerated desicca- 
tion of the skin surface leads to friability of the epidermis and to relapses. 
On the other hand, mild powders, reducing the irritation (amylum and 
talcum preparations), have sometimes a very favorable effect in the 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 125 

acute stages of conchial eczema. Local applications of yeast (mycoder- 
min) or other yeast preparations (levulose, furunculin), used as pow- 
ders, are likewise beneficial. 

X-ray treatment is attended with surprisingly good, rapid, and 
permanent results in many cases of chronic squamous eczema. 

I am in the habit of prescribing in all cases of eczema the internal 
administration of mycodermin (1 teaspoonful 1-4 times daily) and also 
arsenic in the form of Fowler's solution or "Levico" water. Improve- 
ment of the general condition, forced feeding, and a stay in a properly- 
selected country place are often very serviceable. 

io. OTITIS EXTERNA FURUNCULOSA; OTITIS EXTERNA FOLLICULARIS 
(FURUNCLE OF THE AUDITORY DUCT) 

Follicular inflammation of the auditory duct occurs from infection 
of the sebaceous glands. The first effect of the infectious germs seems 
to consist in agglutination of the superficial orifices of the sebaceous 
glands; as a consequence, the glandular secretion is retained in the 
glands, causing follicular inflammation and terminating with abscess 
formation owing to the action of the micro-organisms. The follicular 
inflammation always confines itself to the membranous part of the duct ; 
since the osseous part does not contain any sebaceous glands and there- 
fore cannot give rise to folliculitis. The inflammation of the membranous 
portion is either isolated or multiple, and contact of an abscess with the 
opposite wall may cause new inflammatory foci. Constitutional affec- 
tions, under-nutrition, chronic eczema, and exostoses of the auditory 
duct will favor the occurrence of otitis externa follicularis. All affec- 
tions of the auditory duct which produce itching may be the cause of 
folliculitis and infection of the sebaceous glands from patients violently 
rubbing and scratching themselves, thereby producing excoriations. 

Symptoms. — The principal subjective symptom consists in consid- 
erable local pain, which may lead to sleeplessness. Since the anterior 
wall of the auditory canal participates in the movements of the maxillary 
articulation, patients will experience pain when speaking or masticating. 
Alcoholic beverages are apt to aggravate the pain considerably. The 
temperature is usually normal and only in exceptional cases slightly 
elevated. 

Examination. — In introducing the ear-speculum, the ear should 
not be subjected to much pulling. If superficial inspection discloses 
considerable swelling and constriction of the duct, a thin funnel is 
selected, which is greased with a volatile oil to facilitate insertion. In 
the beginning of the affection it is only exceptionally possible to say 
what part of the wall is infected, as all the walls usually participate in 
the swelling. In advanced cases it may be possible at times to locate 



126 



THE DISEASES OF CHILDREN 



the furuncle with the otoscope, without using the funnel. In deep 
furuncles the oedema of the duct will spread to the base and vicinity of 
the concha. In this way it is by no means rare for the cedematous swell- 
ing to involve the skin of the mastoid process (Figs. 64a and 646), the 
parotid region, and in rare cases the inferior eyelid and the upper neck. 
In the latter case the mobility of the head and neck is interfered with, 
and a pathological oblique position of the head may be the result. In 
other cases furunculosis of the external duct may set in with a phleg- 
monous swelling of the base of the ear and the vicinity of the concha. 



Fig. 646. 



Fig. 64a. 





(Edema of the mastoid region with painless swelling, in furunculosis of the right external auditory duct, 
in a girl thirteen years old. The concha of the affected side is entirely deflected and raised above the level 
of the healthy ear. The abnormal position of the concha can be most distinctly observed from the posterior 
aspect. 

Course. — The course of otitis externa furunculosa is always favor- 
able. In some cases it may be protracted, from the fact that new ab- 
scesses form by contact and new inflammatory foci develop. Failing 
competent treatment, extensive granulations may occur, which rapidly 
increase in size, filling out completely the entire external duct. 

Diagnosis. — Generally speaking, the diagnosis of furuncle of the 
auditory duct presents no difficulties. The furuncle may be directly 
visible, and the healthy condition of the tympanic membrane may be 
established by the otoscope. Unless there are other affections of the 
ear, the acuity will be found normal in the test with the funnel inserted 
for the purpose of keeping the passage clear. 

If the deep parts of the duct and tympanic membrane cannot be 
otoscopically inspected at the first examination, or if the duct is occluded 
by granulations, careful tamponade with xeroform gauze and removal 
of pus and crusts will clear the way. Granulomata may have to be 



DISEASES OF THE CONCHA AND EXTERNAL MEATUS 127 

removed by the sharp spoon or snare before a decision is possible. (Ede- 
matous swelling of the ear caused by the furuncle will usually lead to 
cedematous swelling of the soft covers of the mastoid process. 

Treatment. — Conservative treatment is indicated in the initial 
stages of otitis externa, as long as the auditory duct remains diffusely 
cedematous and the place of the future abscess is not yet discernible. 
Instillations and compresses of warm acetic alumina (1 : 6) or 1 per cent, 
lysol solutions have a very beneficial effect. Exaggerated or unpleasant 
pressure should be avoided when inserting the gauze tampons. Abscess 
formation should be stimulated by application of heat (instillation of hot 
liq. Burrowii, or carbolglycerin, or hot compresses upon the affected 
ear). As soon as perforation has taken place, the aspirating globe may 
be tentatively employed. Treatment with specific vaccine is also to be 
considered in the case of nurslings. The food should consist of fluids, 
and patients should speak as little as possible. All movements causing 
congestion of blood to the head are to be avoided. Easy evacuations 
are essential. 

As soon as the place of the abscess formation has been definitely 
determined by color and swelling, it should be incised with a narrow- 
pointed scalpel, which is introduced into the external duct with its cut- 
ting edge over the furuncle. As the knife is withdrawn, the furuncle is 
longitudinally incised and a moist compress applied. This small opera- 
tion is best carried out under ethyl chloride anaesthesia. 

In local anaesthesia with ethyl chloride, great care should be taken 
to see that the tampon is inserted to a sufficient depth into the osseous 
canal. Anaesthesia by injection is not to be recommended. 

In abundant granulation following perforated abscess, insertion 
and frequent renewal (6-8 times daily) of antiseptic gauze strips (xero- 
form, vioform, etc.) will often effect spontaneous involution. Granu- 
lomata completely filling the duct should be removed by the curette or 
snare. 

Habitual occurrence of furunculosis is sometimes favorably in- 
fluenced by insufflation of mycodermin into the external meatus and 
simultaneous internal administration of the same remedy (1 teaspoonful 
1-4 times daily), preferably together with Fowler's solution, to prevent 
relapses. The ear should not be washed with water for a long time. A 
3 per cent, borlanolinvaseline ointment is applied to the integument of 
the duct once or twice daily. 

Repeated attacks of furunculosis yield most promptly and remain 
cured more often by the use of autogenous vaccine than by any other 
form of treatment. When, however, it is impossible to get such a vaccine, 
the mixed staphylococcus does the most good. 



IX. AFFECTIONS OF THE MIDDLE EAR 

I. TRAUMATIC INJURIES OF THE TYMPANIC MEMBRANE 

The traumatic injuries of the tympanic membrane consist in lesions 
of the epidermal layer and mucosa and traumatic perforation. The 
epidermal layer may be injured during instrumental examination. For- 
eign bodies which have advanced as far as the tympanic membrane give 
rise to circumscribed lesions of the epidermal layer, which may become 
softened and macerated by the pathological process, exposing the tym- 
panic membrane to perforation from injections. The mucosa may be 
injured by a bougie being pushed too far into the middle ear or by being 
bent in the operation. These two kinds of injuries, however, are in 
practice of far less significance than tearing or rupture. 

Rupture may be direct or indirect. In direct rupture the tympanic 
membrane is destroyed by a solid or fluid substance advancing against 
the object of destruction. Indirect rupture is caused by condensation 
of air in the external auditory canal or middle ear, overtaxing the elas- 
ticity of the tympanic membrane. Indirect ruptures are far more 
frequent. 

1. DIRECT RUPTURE OF THE TYMPANIC MEMBRANE 

Direct rupture of the tympanic membrane is caused by perforation 
through pointed articles which have gained access to the external meatus, 
such as matches, toothpicks, lead-pencils, hair-pins, pen-holders, straws, 
peduncles of flowers or plants, wire, etc. Self-introduced articles rarely 
lead to rupture, for the reason that the osseous duct is very sensitive 
and even slight pressure gives rise to a very disagreeable sensation. 
Thus, self-induced rupture could occur only in hypsesthesia of the ex- 
ternal duct and tympanic membrane, in very torpid individuals, or in 
extremely tormenting itching. Otherwise, rupture will occur by an 
article, lodged in the external duct, being accidentally propelled forward 
by a blow. Another danger is that fragile articles which have found 
their way into the tympanic cavity may break from the force of the 
blow. In such a case the foreign body can not be seen at all in the oto- 
scopic picture, or the broken end will protrude through the rupture into 
the external duct. 

However, all foreign bodies which have advanced beyond the 
isthmus into the osseous duct may cause traumatic injuries and rupture 
of the tympanic membrane. The mere penetration of water may cause 
traumatic rupture, especially when the resistance of the tympanic 
membrane has been impaired by catarrhal affections of the middle ear, 

128 



AFFECTIONS OF THE MIDDLE EAR 129 

or when very thin circumscribed scars of the tympanic membrane are 
torn by a jet of water. Ruptures caused by falling or jumping into the 
water head foremost are nearly always of the indirect variety. 

Direct rupture may also lead to secondary injuries, such as acute 
swelling of the tympanic mucosa, hemorrhage, or otitis media, when 
the fluid has penetrated into the middle ear. 

In direct rupture the auditory duct is sometimes full of blood, and 
traumatic injuries of the integument may render an otoscopic examina- 
tion difficult or impossible at the first sitting. 

2. INDIRECT RUPTURES OF THE TYMPANIC MEMBRANE 

occur from sudden condensation or attenuation of the air within the 
duct. The most frequent cause is a blow on the ear with the flat hand, 
not necessarily violent. The conditions most favoring this result are 
impaired resistance of the tympanic membrane and complete occlusion 
of the air within the duct at the moment of the blow, preventing the 
lateral escape of the air contained in the concavities of the concha and 
the external duct. 

The next frequent cause of indirect rupture is a fall into the water, 
especially an unsuccessful head jump in the swimming bath, the water 
being liable to penetrate into the tympanic cavity and cause serous or 
purulent otitis media. Tender and thin scars of the tympanic membrane 
are likewise liable to be ruptured from forcible penetration of air. Ex- 
plosions, detonations, falling from high altitudes, may cause rupture 
through concussion and air pressure, but these ruptures would be better 
classified under air concussions. 

Symptoms. — Indirect ruptures may be without symptoms, espe- 
cially when cicatrization has impaired the resistance of the tympanic 
membrane and the hearing acuity has not been normal before the rupture. 
The pain experienced in rupture of a normal tympanic membrane may 
be entirely absent in the destruction of a tender scar. Similarly, the 
slight reduction in hearing acuity may not be noticed in previously 
abnormal conditions, slight impairment of hearing being perceived only 
in injuries to a completely normal ear. The greater the functional 
injury before the trauma, the greater is the possibility of a further de- 
terioration escaping the attention of the patient. 

In most cases the occurrence of rupture is perceived as a short 
stabbing pain, often associated with a subjective noise, such as the per- 
ception of a high note or considerable tinnitus. More or less pain may 
be felt for several hours or days afterward, or there may be headache 
and vertigo. Occasionally, a tormenting sensation of fulness in the ear, 
numbness, headache, and nausea may persist for some time. 

It is in the nature of the accident that patients are apt to exaggerate 

VI— 9 




130 THE DISEASES OF CHILDREN 

the complaint, notably in cases of forensic importance. Thus, a previous 
affection of the ear is said to have become much worse, the hearing 
distance reduced, profuse ulceration is stated to have set in again in 
chronic ulceration of the middle ear which is previously supposed to 
have been more or less arrested. 

In the presence of simultaneous injuries to the external ear, there 
will of course be regional symptoms in addition to those of rupture. In 
suffusions, tears, and contusions of the concha, or injury to the entire 
facial hemisphere, the real rupture symptoms will be quite subordinate 
to the severer symptoms of the totality of the injuries. 

Otoscopic Findings. — In fresh cases there is either a slit-like, radial, 
or irregular fissure in the tympanic membrane (Fig. 65). The edges of 
the rupture are often irregular, fringed, or there is an angular tear with 
the flap folded upon the tympanic cavity or the external duct. 

The edges are tinged with blood, while 
the rest of the mucous membrane is either 
unchanged or infiltrated with punctiform 
hemorrhages. The rupture is sometimes 
followed by extravasation of blood through 
the external duct, the source of which can 
i 2 be detected at the lateral surface of the 

Traumatic rupture of the tympanic mem- tympanic membrane. The fundus of the 

brane after a blow on the ear. 1. Slit-like .... • c i i ,1 

radial rupture of the left tympanic mem- rupture in indirect cases is formed by the 

brane; three hours after injury. 2. Cir- -i j j. -i , • iij.1 i 

cuiar rupture, larger than a hemp-seed, of Unchanged, medial tympanic wall, the yel- 
nve d; y s r af P t h er C infu h ry tympanic membrane; low bone color of which is in marked con- 
trast to the red margin of the perforation. 
Rupture of the two anterior quadrants is more frequent than those of 
the two posterior ones. In ruptures occurring on the otoscopic level of 
the stapes, window of the labyrinth, chorda tympani, etc., these parts 
will of course be seen through the rupture, and present the characteristic 
optic displacement, upon the examiner moving his head, as is observed 
in parallactic displacements of the eye. 

Examination. — First establish the otoscopic findings. If the in- 
spection of the tympanic membrane is impeded by a ceruminal embolus, 
crusts, blood coagula, etc., these obstacles may be carefully removed 
with sterile forceps, provided there is no suspicion of a fracture or fissure 
of the base of the skull. In the presence of such a suspicion, all manipu- 
lations of the external duct are to be deprecated in fresh cases. Syring- 
ing is absolutely contraindicated. 

Valsalva's test will serve to demonstrate the characteristic rupture 
noise. In all cases where the tube is freely permeable and the ear has 
been normal before the injury, the air will escape through the rupture 
with a deep breathing noise. 



AFFECTIONS OF THE MIDDLE EAR 131 

If the tube was pathologically affected and is not permeable for 
the air current in a pharyngo-tympanal direction, the so-called reversed 
arrangement after Politzer is employed. By means of Siegle's funnel or 
Gelle's bulb, weak compressions are made in the external duct, the air 
escaping into the pharynx. The noise hereby produced can be distinctly 
perceived through the otoscope introduced into the nares, with patient's 
mouth kept open. A very convenient and convincing test is Kugel's. 
The otoscope — or, preferably, a rubber tube, 15 to 20 cm. long — is 
conducted into a glass of water, and, on application of Valsalva's test, 
air bubbles will be seen to escape through the water. The noise is in 
many cases audible at a great distance; in others it is so weak that it 
can be perceived only through the otoscope. 

The functional test of the auditory duct reveals a slight obstacle 
to sound-conduction in uncomplicated cases, the rupture having caused 
slight reduction of the hearing acuity. The functional examination of 
the labyrinth is extremely important and should be made in all cases of 
traumatic injury of the ear. In cases of uncomplicated traumatic rup- 
ture the tympanic membrane can, of course, present no symptoms, 
being perfectly normal. 

In complicated cases there will be spontaneous nystagmus and 
labyrinthine vertigo, or even equilibrial disturbance and vomiting. 

Diagnosis. — If the history warrants and the otoscopic findings are 
distinct, the diagnosis of rupture offers no difficulties, especially if the rup- 
ture noise can be physically demonstrated. The irregular, sanguineously 
diffused margins in fresh cases are characteristic of traumatic rupture. 
In older cases the rupture may have assumed a circular shape with a 
white margin (corresponding to the young, new-growing epidermal 
layer), and the blood coagula may have been resorbed. This will render 
the differential diagnosis between traumatic and pathologic perforation 
of the tympanic membrane difficult; with incomplete history and in 
the absence of signs of healed old catarrh or purulent inflammation, the 
differentiation may be impossible. Furthermore, the place of rupture 
and coagula may change position, being shifted from the centre to the 
edge of the membrane. 

Treatment of uncomplicated rupture of the tympanic membrane is 
confined to protection from injurious extraneous influence. The audi- 
tory meatus is closed with gauze, all manipulations are contraindicated, 
including, of course, every kind of irrigation or instillation. 

Course. — In uncomplicated cases the gap will gradually close and 
the destroyed part of the tympanic membrane will be restored. In 
small circular ruptures up to the size of a hemp-seed, the membrane will 
be completely regenerated, so that the perforation will be perfectly 
closed by tympanic tissue, provided the membrane has been normal 



132 THE DISEASES OF CHILDREN 

before rupture. After the healing process is completed, the original seat 
of the rupture can no longer be traced, as the newly-formed tissue does 
not differ in any way from the rest of the membrane. 

In atrophic conditions of the tympanic membrane in the region cf 
the rupture there is usually new-formation of an atrophic membrane, 
but cases occur in which the newly-formed part is less atrophic than 
the one destroyed. According to the extent of considerable traumatic 
destruction of the tympanic membrane, there is danger of an atrophic 
scar closing the gap after healing has taken place. In complicating in- 
flammatory processes of the middle ear there is, aside from the danger 
of purulent otitis media, the possibility to be reckoned with that syne- 
chias will form during the healing process, or that a permanent gap will 
form after the margins have been invested with epithelium. In angular 
rupture the peripheral part of the resulting flap may become necrotic, 
but healing will take place after desquamation. Some authors recom- 
mend removal of the irregular margins, but this is not only superfluous 
but even dangerous, since all instrumental manipulations of the ruptured 
tympanic membrane or the exposed mucosa of the middle ear may lead 
to otitis media. 

The time required for healing depends upon the size of the gap and 
individual conditions. Ruptures from a millet-seed to a hemp-seed in 
size heal in 4-6 weeks. After the gap has healed the former hearing 
acuity, which is never much impaired in uncomplicated cases, will be 
fully restored, and a previously normal ear will again become perfectly 
normal. Complicated cases may end in permanent impairment of 
hearing, which, however, is not attributable to the rupture, but to the 
complication (acute catarrh of the middle ear, purulent otitis media, 
concussion of the lobe) and its sequelae. 

It may be mentioned that uncomplicated ruptures of the tympanic 
membrane, aside from the time required for healing, are to be regarded 
as slight injuries in a forensic respect. 

II. INFLAMMATORY INFECTIONS OF THE TYMPANIC MEMBRANE 

1. ACUTE INFLAMMATIONS OF THE TYMPANIC MEMBRANE 
(MYRINGITIS ACUTA) 

Etiology and Occurrence. — Acute inflammation of the tympanic 
membrane is a frequent affection in childhood. It may occur as a pri- 
mary inflammation without any known cause or after catching cold; 
as a rule, however, it is the forerunner of acute otitis media. It may, 
however, also be caused by direct or indirect traumatic injury of the 
external auditory canal or in connection with the removal of foreign 
bodies. Furthermore, all traumas which cause rupture of the tympanic 
membrane may cause its inflammation. 



AFFECTIONS OF THE MIDDLE EAR 133 

The anatomical changes consist in hyperemia and oedema of the 
membrane, sometimes with formation of cysts of the lateral surface 
(exudative sacs). The exudate usually harbors demonstrable pathologic 
micro-organisms; other times it is sterile. Acute myringitis occurs either 
in one or both ears. 

Symptoms. — There are stinging pains in the ear, which, however, 
do not attain to great severity and are sometimes merely indicated by 
the organic sensation of the tympanum. Hearing acuity is slightly 
diminished and the temperature is normal. Otoscopic examination 
always shows acute hyperemia, sometimes also swelling, both in a 
considerably varying degree. Thus, in some cases the membrane appears 
unchanged with the exception of a radial vascular injection, in others 
there is diffuse hyperemia; the line of the manubrium is either blurred 
or quite invisible, due to oedema. The cysts, if visible, are small and 
thin-walled, varying in size from a millet-seed to a small pea. They 
contain serum which is either limpid or blood-tinged; if purulent, which 
is rarely the case, they are yellow and opaque. With yellow and clear 
serum, the otoscopic picture resembles in color and lustre that of se- 
cretory catarrh of the middle ear. The lateral wall of the tympanic 
cysts is formed by the epidermal layer of the tympanic membrane; the 
medial wall, by the remaining layers of the tympanic membrane (sub- 
stantia propria and mucosal layer) . There is no communication between 
the cysts or their contents and the tympanic cavity. Cyst formation 
is more frequently observed in the posterosuperior quadrant than in 
the other parts of the membrane. 

Functional examination demonstrates in all cases an uncomplicated 
slight obstacle to sound-conduction. 

The diagnosis of acute inflammation of the tympanic membrane 
is based upon the otoscopic findings. To make a differential diagnosis 
from simple acute (serous) inflammation of the middle ear the slight 
degree of functional disturbance, slight pain, and normal temperature 
have to be considered. There can be no diagnostic difficulties, as simple 
inflammation of the middle ear always commences with much pain and, at 
least during the first days, with considerable impairment of hearing; 
there is also elevated temperature in most cases. * 

Course. — The course of the affection is favorable in many cases, 
the symptoms completely disappearing in a few days, and normal hear- 
ing returning within a week, with complete restoration of the normal 
picture of the membrane. In other cases, however, the affection is the 
forerunner of acute simple or purulent inflammation of the middle ear. 
The change from an inflammation of the tympanic membrane to one 
of the middle ear is plain from the rapid reduction of the hearing acuity, 
the increase of subjective complaints, and the elevated temperature. 



134 THE DISEASES OF CHILDREN 

It is a noteworthy fact that, where inflammation of the middle ear is the 
result of inflammatory changes of the nasopharyngeal tract, an habitual 
tendency to relapses may persist, causing — with every coryza, for in- 
stance — inflammation of the tympanic membrane, with or without 
formation of exudative sacs. This may finally lead to atrophy of the 
tympanic membrane. 

The treatment of acute myringitis is identical with that of acute 
simple (serous) inflammation of the middle ear, for which see p. 156. 

2. SUBACUTE AND CHRONIC INFLAMMATION OF THE TYMPANIC MEM- 
BRANE (MYRINGITIS SUBACUTA AND CHRONICA) 

Light degrees of subacute and chronic myringitis are of very fre- 
quent occurrence in childhood, and may develop from the acute stage 
owing to adenoid vegetations or where the nasopharyngeal tract has 
been disturbed by other changes. The subjective complaints disappear 
with the acute stage, but slight impairment of hearing and injection of 
the tympanic blood-vessels will persist for some time. The dull, gray- 
red, retracted tympanic membrane of childhood is almost pathogno- 
monic for the presence of adenoids. The findings in subacute and chronic 
myringitis are not always constant, as temporary improvement may 
occur at any time, during which the picture of the tympanic membrane 
acquires an approximately normal appearance. Should the causative 
factor persist, there may be periodical aggravations, during which 
hyperemia is increased and serous or purulent otitis media develops. 

The ulcerative form of chronic inflammation of the tympanic mem- 
brane (myringitis chronica ulcerosa) is a rare affection, and consists of 
ulceration and chronic purulent inflammation of the tympanic mem- 
brane, the ulcerations occurring on the middle as well as the lateral 
surfaces. Otoscopically, they are only visible at the lateral surface. 

Myringitis ulcerosa occurs during periods of abatement of chronic 
ulcerations of the middle ear, or as an independent affection in debili- 
tated, anaemic, or tuberculous individuals without any known cause. 

The diagnosis is made on the otoscopic findings of the ulcerations. 

The course is unfavorable in many cases, as there is gradual develop- 
ment of suppuration of the middle ear. In other cases, however, it is 
favorable, and a complete cure will result under appropriate general 
and local treatment. 

The treatment of myringitis ulcerosa consists in cauterizing the 
ulcerated surface with chromic acid pearl, ferum sesquichloratum, or 
trichloracetic acid. Improvement of the general condition of nutrition 
by forced feeding, sojourn in the country or at the seaside, and sea 
baths, etc., is of importance. With an increase in weight there is often 
spontaneous involution after a case has proved refractory to all local 



AFFECTIONS OF THE MIDDLE EAR 135 

treatment. Where chronic meningitis is a part manifestation of sup- 
puration of the middle ear, only the latter calls for treatment. 

III. CATARRHAL AFFECTIONS OF THE MIDDLE EAR 

Catarrhal affections of the mucosa of the middle ear are associ- 
ated with swelling of the mucosa and secretion of an exudate which, 
in fresh cases, is serous, limpid, and light yellow; in chronic cases, pur- 
ulent in various degrees. Microscopically, the exudate contains a small 
number of mononuclear leucocytes and mast-cells, as well as various 
bacteria, mostly degenerated. Clinically, the exudate is of very little 
importance in many cases; in chronic cases it is entirely absent. All 
middle-ear catarrhs in which there is considerable exudation are com- 
prised in the generic name of "exudative middle-ear catarrh," as differ- 
entiated from all others (Politzer). 

Etiology. — Middle-ear catarrhs are primarily traceable to acute or 
chronic changes of the nasopharyngeal tract in the majority of cases. 
The principal etiological factor in children is enlargement of the faucial 
toDsil (adenoid vegetations). Of further etiological importance are all 
so-called colds. All affections associated with hyperemia and catarrhal 
changes of the nasopharyngeal tract may lead to catarrhal involvement 
of the middle ear in the acute as well as later in the chronic stage. Dis- 
turbed ventilation of the tympanic cavity always leads sooner or later 
to catarrhal affection of the middle ear. If the pharyngeal opening of 
the tube has become impassable from swelling of the mucosa or is con- 
stricted or occluded by a tumor, the physiological function of the tube 
is interfered with, leading to disease of the middle ear. Furthermore, 
catarrh of the middle ear is a typical concomitant manifestation of the 
etiological primary affection in disturbed motility of the tubal muscula- 
ture, paralysis of the velum palatum, uranoschisis (cleft palate), naso- 
pharyngeal tumor, tumor of the superior maxilla, syphilis, nasal tuber- 
culosis, rhinoscleroma, etc. It is only rarely that catarrh of the middle 
ear follows traumatic injury of the tympanic membrane, tympanic 
cavity, or Eustachian tube. Noxious fumes or gases may indirectly 
cause catarrhal affection of the middle ear; the fumes first produce 
catarrh of the nasopharyngeal mucosa, from which the inflammation 
spreads to the tubal mucosa and thence to the middle ear. Finally, 
catarrh of the middle ear may be a deuteropathic manifestation of healed 
purulent otitis media. 

Operations of the nasopharyngeal tract, hard or soft palate may be 
the cause of catarrhal affections of the middle ear due to the reactive 
swelling of the nasopharyngeal mucosa. 

1. Acute catarrh of the tube generally develops at the climax 
of acute colds (coryza), and is often observed in children as an early 




136 THE DISEASES OF CHILDREN 

stage of acute infections. The otoscopic findings (Fig. 66) show no changes 
save a retraction of the tympanic membrane. The hearing acuity is 
not materially reduced; sometimes there is a feeling of fulness in the 
ear, which may be accompanied by subjective noises. As the inflamma- 
tory changes abate in the nasopharyngeal space, the tubal catarrh will 
heal within a few days without any local treatment. 

2. Acute catarrh of the tympanum is rather rare and exclusively 
due to the influence of trauma in the auditory canal. It is occasioned by 
the penetration of hot steam into the latter (explosions, etc.) ; further- 

fig. 66. more, catarrh restricted to the tympanic cavity may occur 

in cases of rupture of the tympanic membrane, if a foreign 
body advances into the middle ear through the opening 
of the rupture (direct injury from toothpicks or matches, 
indirect injury from penetration of water). A more fre- 
quent sequel to this injury, however, is purulent otitis 

Considerable re- rn(i Ai a 
traction with pro- iiicviici. 

o fTht P poste U rio r n Th e course is usually favorable. (Edema and hyper- 

superior and ante- ge m i a f the mucosa of the middle ear, which can be well 

nor folds of the 7 

tympanic mem- observed through the rupture, rapidly abate, and the im- 

brane. . .,. '.■■••' ' 

paired hearing distance soon returns to normal. As to 
therapeutic measures, it is sufficient to cleanse the external duct with 
dry cotton tips or squeezed-out peroxide swabs, closing the same with 
antiseptic or sterile gauze strips. 

3. Acute and subacute catarrh of the middle ear (secretory 
middle-ear catarrh, catarrhus recens) is usually a sequel to colds, or 
rather to the catarrh of the upper air-passages resulting therefrom 
(particularly of the nose and nasopharynx) . 

The principal symptom of exudative middle-ear catarrh consists 
in a more or less pronounced reduction of the hearing acuity (down to 
33^-10 feet C), which may develop in the course of a few hours. There 
may also be subjective noises (falling of drops), unless the middle-ear 
spaces are completely filled with exudate; sometimes there is a sensation 
of fluid in the ear, participating in the movements of the head and body, 
and causing a characteristic splashing noise. 

There are still to be mentioned sensation of fulness and pressure 
in the ear, numbness in the head, and resonance of patient's own voice. 
Painful sensations are not rare in middle-ear catarrh with acute onset; 
they are not caused by the catarrhal affection itself, but by the simul- 
taneous acute inflammatory changes of the nasopharyngeal tract, the 
latter being also exclusively responsible for any possible elevation of 
temperature. 

Otoscopic examination shows normal position or slight retraction 
of the tympanic membrane. The lustre of the membrane is increased, 



AFFECTIONS OF THE MIDDLE EAR 137 

the light reflex is more intense, giving the impression as if the membrane 
were varnished, the yellow exudate imparting its color to the membrane. 
If the entire mesotympanum is filled with exudate, the whole of the 
tympanic membrane is tinged yellow (Plate VIII, Fig. 1). When there 
is any residue of air in the tympanic cavity, the lower, yellow part of 
the membrane is sharply demarcated against the gray upper part through 
the meniscus formed by the fluid (Plate VIII, Fig. 2). This line of 
demarcation closely resembles a hair in the otoscopic picture and is 
always distinctly visible. Changing the position of the head causes 
the demarcation line to change also, the fluid gravitating toward the 
lowest point of the tympanic cavity. This line is in many cases more 
or less straight, in others simply curved or undulated. It extends over 
the entire width of the membrane or, as the exudate increases, it is 
confined to the anterior or posterior half of the membrane. The in- 
creased lustre of the tympanic membrane is occasioned by osmosis, 
and from the same cause the manubrium appears thin and narrow. In 
the normal otoscopic picture the strip denoting the latter represents 
not only the bone, but also the connective tissue encircling it (Fig. 25, c, 
Plate VIII, Fig. 1). For this reason the manubrium appears thicker in 
the normal otoscopic picture than in the skeleton. If now the tympanic 
membrane is humidified through osmosis, the rest of the membrane and 
the connective tissue encircling the manubrium become transparent, 
and nothing but the bone is visible in the shape of a sharply demarcated 
yellow strip. 

The functional test shows all the signs of an obstacle to sound- 
conduction in uncomplicated cases. 

Only the smallest part of the exudate comes from the catarrhal 
mucosa of the tympanic membrane, the greater portion emanating from 
the aspirated secretion of the mucous glands of the tube, as the catarrh 
sets in with occlusion of the tube. The tympanic cavity is no longer 
ventilated and the air contained in it is partly resorbed. In this 
way the over-pressure of the outer air causes passive retraction of 
the tympanic membrane. The tympanic cavity, containing rarefied air 
or none at all, aspirates the secretion of the tubal glands, which, besides, 
is increased from catarrh. As this secretion cannot escape through the 
pharynx, it wanders upward into the tympanic cavity. This form of 
exudation is called passive. Active exudation, in which the exudate 
is under considerable pressure in the middle-ear spaces, always causes 
the tympanic membrane to bulge out. Active exudation of this kind 
always occurs in serous as well as in purulent otitis media. 

The diagnosis offers no difficulties. Doubtful cases should always 
be examined in daylight, as the yellow or yellowish-brown coloration 
of the tympanic membrane is then particularly distinct. 



138 THE DISEASES OF CHILDREN 

Treatment. — There should be no local treatment whatever in 
the first days of illness. The patient should remain in bed if the tem- 
perature is elevated. In the evening he is given hot lemonade and an 
infusion of tilia flowers and aspirin (children 0.15-0.5 Gm., according to 
age; adults 1-2 Gm.). Violent perspiration often causes spontaneous 
improvement of the ear trouble. If the body temperature is normal 
and the acute catarrhal or inflammatory manifestations of the nose and 
throat have subsided, applications of the Politzer air-douche, twice or 
three times weekly, may rapidly improve the hearing acuity and com- 
pletely cure the affection in 1-2 weeks. In applying the air-douche, 
the longitudinal axis of the rubber tube is placed in a vertical direction. 
The patient keeps a draught of water in his mouth; his head is inclined 
toward the healthy side and turned toward the affected side, and in 
this position the air is injected. The air ascends in the middle ear- 
space and the exudate is displaced by the air, escaping downward through 
the vertical tube. 

Insufflation of air serves instantaneously to atomize, aerize, or 
displace the entire exudate, which will either be pushed into the antrum 
and cavities of the mastoid, or else flow off through the tube. However, 
exudate will collect again in the tympanum in the next few hours. Ex- 
amination of the patient 24 hours after insufflation of air will still show 
demonstrable exudate in cases taking a favorable course, but in reduced 
quantities. Where previously the entire tympanum was filled with 
exudate, there is now a line of demarcation; where there was a border 
line before, it now occupies a lower position. 

Where the conservative treatment fails, there are always renewed 
accumulations of exudate, and the only remaining remedy is paracen- 
tesis. The aperture thereby made admits air into the tympanic cavity, 
the hearing distance is at once increased, and in many cases there is 
spontaneous evacuation of the exudate. Should there be no spontaneous 
evacuation, the exudate may be forced out by insufflation of air either 
at once or twenty-four hours after paracentesis. 

As a matter of course, all aseptic precautions should be observed 
in doing a paracentesis; nevertheless, it may not always be possible in 
acute cases to prevent postoperative purulent inflammation of the middle 
ear. The mucopurulent secretion usually persists for 1-2 weeks, but is 
finally completely arrested. The danger of postoperative purulent 
otitis media is particularly great where there is a transition form of 
exudative catarrh into acute serous inflammation of the middle ear 
(Plate VIII, Fig. 6). 

In the differential diagnosis, both for children and adults, otoscle- 
rosis should be considered. In the initial stage or at the climax of atyp- 
ical otosclerosis there are sometimes true exudative processes of the 



AFFECTIONS OF THE MIDDLE EAR 139 

middle ear. As a matter of course, the prognosis of these exudates is 
unfavorable in view of the fact that otosclerosis is the primary affection. 
The suspicion of otosclerosis, hidden behind the picture of exudative 
catarrh, is justified if there was impaired hearing before the middle ear 
became affected or if insufflation of air for test purposes did not lead to 
any material improvement of the hearing acuity. 

4. Chronic tubal catarrh is a rather rare affection, since chronic 
catarrhal affections of the tube very soon involve the entire middle ear 
in the majority of cases. Otoscopic examination shows considerable 
retraction of the otherwise unchanged tympanic membrane. The short 
process and the posterior tympanic fold protrude considerably; Shrap- 
nell's membrane is much retracted. The otoscopic picture sometimes 
simulates perforation of Shrapnell's membrane, and it must be left for 
examination with Siegle's speculum to demonstrate the condition of 
the highly retracted membrane. The tube is either of normal width or 
constricted by swelling of the mucosa. 

Hearing acuity is variable, patients hearing sometimes very well 
and at other times very imperfectly. There is numbness in the head, 
and there are usually deep, tormenting subjective noises. Catheteriz- 
ing of the Eustachian tube causes crepitant rales; Politzer's tuning- 
fork test is negative. 

Prognosis and treatment of chronic tubal catarrh are chiefly de- 
pendent upon the primary affection of the nasopharynx. The progno- 
sis is favorable if the affection is caused by remediable changes, such as 
adenoid vegetations, hypertrophy of the nasal septum, pathological enlarge- 
ment of the nostrils, or acute ulceration of the accessory cavities. When 
these obstacles are removed, the hearing distance becomes and remains 
normal after short treatment, consisting in Politzer's method of air 
insufflation, applied two. or three times a week. On the other hand, 
permanent improvement is impossible if the tubal catarrh is caused by 
irreparable or chronic purulent changes in the nasopharyngeal space 
(malignant tumor, chronic ulceration of the accessory cavities, deform- 
ities or defects of the hard palate). In these cases the catheter can only 
free the patient for some time from an ear trouble which is often very 
grave. If the nose is impassable, the catheter will have to be introduced 
through the oral cavity. The considerable retraction of the tympanic 
membrane usually causes subjective hearing sensations from which 
patients suffer more than from impaired hearing. This condition can 
momentarily be relieved by the application of Delstanche's massage 
instrument, used as an aspirating apparatus. 

A child suffering from chronic tubal catarrh can only with difficulty 
follow his school lessons, owing to the periodical or permanent impair- 
ment of hearing acuity, and will therefore be a backward pupil. 




140 THE DISEASES OF CHILDREN 

5. Chronic catarrh of the middle ear in early childhood is 
primarily traceable to chronic changes in the nose and nasopharyngeal 
space, and particularly to adenoid vegetations. The highly disturbed 
physiological function of the tube gradually leads to grave deutero- 
pathic manifestations of the tympanic membrane and the mucosal fold 
of the tympanic cavity, the result being circumscribed or diffuse atrophy, 
considerable retraction of the tympanic membrane, and bulging of the 
posterior fold of the membrane (Fig. 67). The retraction may become 
so considerable that in the otoscopic picture the manubrium appears 
to be behind the tympanic fold and is therefore invisible. 

Chronic catarrh of the middle ear in childhood undergoes many 
variations in the course of time. Under the influence of colds, coryza, 

infectious diseases, etc., it may 
lead to acute exacerbations 
and acute inflammatory irrita- 
tions of the middle ear. In 
other cases chronic exudative 
catarrh or a chronic adhesive 
process may develop. 

Tympanic membranes in catarrhal affections of the middle The treatment should be 

ear. 1. Healed middle-ear catarrh; kidney-shaped atrophy , • j -■+!-, 

of the posterior, superior, and inferior quadrants. 2. Chronic energetic anQ COimiienCe Wltn 

middle-ear catarrh; central atrophy. 3. Chronic middle-ear f K nq<?rmhflrvncrPfll trqpt 

catarrh; high-grade retraction; central atrophy. lll{ = UdS>UpUdI\ IlgtMJ. ITdCL. 

The air-passages should al- 
ways be made permeable by operative interference, removing all obstacles. 
After one or two weeks' intermission there is sometimes spontaneous 
improvement of the catarrh and hearing acuity. 

Gaertner's rhinometer is an excellent instrument for measuring 
the precise permeability of the nose for air currents. 

Further improvement in the hearing acuity may then be effected 
by air insufflation two or three times a week and by aspiration with a 
bulb or Delstanche's massage instrument. Entirely normal hearing 
will result only in the rarest of cases. Valsalva's experiment should be 
rigorously forbidden, as it conduces to extend the atrophy in whatever 
degree it may be present and eventually cause traumatic rupture of 
the tympanic membrane. 

The prognosis depends upon the functional findings. It is favorable 
if at the first examination equalization of air pressure by insufflation 
materially improves the hearing acuity. With only moderate improve- 
ment, a complete restoration of function cannot be expected, even when 
the therapeutic measures are strictly observed. In some cases indeed 
the gradual transition of simple chronic middle-ear catarrh into the 
more unfavorable chronic adhesive process cannot be arrested. 

6. Chronic exudative middle-ear catarrh is either a continu- 



PLATE VIII. 









^ 





12 



13 






Pathological otoscopic findings of the tympanic membrane. 
Explanation of Illustrations. 



Enlarged 2:1. 



Fig. 1. Acute secretory catarrh of the middle ear: Tympanic membrane tinged wine-yellow or amber- 
yellow; lustre increased; line of manubrium narrow. 

Fig. 2. Acute secretory catarrh of the middle ear: Lower part of the tympanic membrane tinged yellow, 
the upper part has the normal bluish-grav tint. The yellow part is demarcated upward by the meniscus of 
the fluid. 

Fig. 3. Chronic adhesive process: Tympanic membrane considerably retracted, posterior and anterior 
folds of the tympanic membrane very distinct, membrana tensa atrophic, reflex well preserved; two central 
glistening scaTS. In this case the chronic adhesive process has developed as a sequel to repeated catarrhal 
affections of the middle ear. 

Fig. 4. Chronic adhesive process after cured middle-ear suppuration: Preserved perforation of the 
posteroinferior quadrant; intermediary lime deposits anteroinferiorly; the posterior and superior parts of the 
tympanic membrane are diffusely atrophied. 

Fig. 5. Acute epitympanic inflammation of the middle ear, with principal involvement of the antrum 
with protrusion and injection of the posterosuperior quadrant of the tympanic membrane. 

Fig. 6. Transition form of secretory catarrh into acute serous inflammation: Frequently found in 
childhood in the presence of adenoid vegetations. The lustre of the tympanic membrane is preserved, the 
latter showing a yellowish-red coloration. 

Fig. 7. Acute purulent otitis media with considerable protrusion of the entire tympanum; the line of 
the manubrium, which is indicated by a narrow furrow, cannot greatly participate in the protrusion. 

Fig. 8. Chronic tuberculous suppuration of the antrum, with small, fissure-like perforation of the pos- 
terosuperior quadrant; the tympanic membrane is turbid and dull, and the line of the manubrium is blurred 
through being encircled by connective tissue. 

Fig. 9. Chronic suppuration of the middle ear, with principal involvement of the tube and hypotym- 
panum; perforation the size of a hemp-seed in the anteroinferior quadrant. 

Fig. 10. Chronic suppuration of the middle ear with acute relapses: The chronic ulceration of the mid- 
dle ear corresponds to the oval perforation of the posteroinferior quadrant and the granulation of the tympanic 
cavity. Part of the granulations of the promontory and the rest of the middle wall of the tympanic cavity 
are visible in the gap of perforation. In this case the chronic suppuration has led to the formation of a sep- 
tum in the mesotympanum, so that the developing acute epitympanic otitis is associated with considerable 
bulging of the posterosuperior quadrant, which largely covers the line of the manubrium. The secretion ac- 
cumulated behind it could not escape through the perforation and had to be evacuated by paracentesis in t he 
posterosuperior quadrant. 

Fig. 11. Chronic suppuration of the middle ear with extensive double perforation: The middle wall of 
the tympanic cavity is covered with granulations; in the anteroinferior quadrant in the area of the tympanic 
ostium of the tube there are three broad ligamental layers of connective tissue. In this case there were con- 
siderably reduced hearing acuity and irritative manifestations of the static labyrinth in the form of vertigo, 
equilibrial disturbance, and pathologically increased labyrinthine reflex excitability. 

Fig. 12. Chronic suppuration of the attic and antrum with formation of a racemose granulation polyp. 

Fig. 13. Chronic suppuration of the middle ear with destruction of the tympanic membrane: Con- 
centrically striated cholesteatomeus plates are visible in the perforation. 



AFFECTIONS OF THE MIDDLE EAR 141 

ation of the acute condition or it arises from the fact that in chronic 
simple middle-ear catarrh the secretion of the tubal glands is aspirated 
into the tympanic cavity owing to air resorption in the latter. 

The findings of the tympanic membrane are usually characteristic. 
To begin with, there are all the signs of chronic catarrh: retraction, 
protrusion of the posterior fold, striated or cloudy turbidity, cicatriza- 
tion, atrophy, etc. To these signs are added the diagnostic symptoms 
of the tympanic exudate: increased lustre of the tympanic membrane 
(saturated membrane), narrow line of the manubrium, the characteristic 
yellow color, emanating from the exudate, at places where the tympanic 
membrane has retained its normal transparency or, owing to atrophy, 
is more transparent than usual. In the presence of widespread atrophy 
the various parts are sharply separated by protruding crests; each 
atrophied place is considerably retracted, injected, and has puncti- 
form light reflexes. 

The diagnosis presents no difficulties if the yellow coloration of 
the tympanic membrane extends over the entire or a considerable part 
of the field of vision. If, however, the tympanic membrane is thickened 
and, with the exception of a few atrophied places, shows gray or grayish- 
white discoloration or calcification, the yellow color is -only noticeable 
at the small atrophied places or may be entirely absent, and then the 
diagnosis must be made on the strength of the increased lustre, osmosis 
of the tympanic membrane, and the narrow line of the manubrium. But 
even with this reduced number of signs the experienced physician will 
have no difficulty in arriving at a diagnosis. 

Treatment consists in evacuation of the exudate by paracentesis. 
Spontaneous evacuation should be waited for before further interference, 
in order to prevent postoperative inflammatory irritation or suppura- 
tion. The auditory meatus is closed with sterile gauze strips. If there 
is no spontaneous evacuation after 24 hours, Politzer's air insufflation 
is applied, or, failing this, owing to extensive tubal changes, the exudate 
is conveyed to the external duct by means of the catheter. The exudate 
is always mucous, stringy, and sometimes consists of nothing but mucus, 
which, after air insufflation, presents itself like a colloid foreign body 
in the external duct through the puncture, where it can be removed 
with forceps. Placed in a formalin solution, this mucous lump soon 
resumes its natural shape, showing a distinct cast of the tympanic 
cavity, antrum, and tubal ostium. 

The further treatment consists in two or three air-douches weekly 
under constant control of the hearing acuity. The puncture completely 
closes in from two to three weeks, after which treatment of the naso- 
pharyngeal tract is proceeded with in order to avoid recurrence of the 
catarrh. 



142 THE DISEASES OF CHILDREN 

7. Subacute recurrent middle-ear catarrh is principally 
observed in children suffering from adenoid vegetations. 

Acute inflammatory swelling of the enlarged faucial tonsil occur- 
ring in the course of a common cold or coryza will in these children 
immediately lead to all the symptoms of middle-ear catarrh. Recurrent 
middle-ear catarrh may sometimes be of the simple and sometimes of 
the exudative type, or of both together, in one and the same patient. 
Without proper treatment these relapses will increase in frequency and 
obstinacy. Examination in the intervals between two attacks may not 
reveal any particular enlargement of the faucial tonsil; nevertheless, 
its removal is imperative, lest the hearing acuity be permanently injured. 
Some of the relapses may be of the ulcerative type, and, if these children 
contract an acute infectious disease, there is considerable danger of 
grave middle-ear infections resulting. 

IV. THE CHRONIC ADHESIVE PROCESS 

The designation of chronic adhesive process (chronic adhesive in- 
flammation of the middle ear) comprises all those affections which 
represent the termination of catarrhal or purulent affections of the mid- 
dle ear. At the present juncture it is proposed to discuss only those ad- 
hesive processes which result from catarrhal affections of the middle 
ear. In the majority of cases they are the final stages of chronic exuda- 
tive catarrh in which the exudate has been gradually organized by 
connective-tissue formation. 

There is, in the first place, thickening and stiffening of the liga- 
ments and mucosal folds located in the tympanic cavity (Fig. 68). 
Superficial or more or. less deep layers of connective tissue develop in 
the tube, which impede its mobility. The act of deglutition has no 
longer any effect upon the tube, or the tubal lumen becomes constricted 
with the result of grave tubal stenosis or stricture, which is most liable 
to appear at the transition of the membranous into the osseous tube. 
Folds and layers of connective tissue develop at the pharyngeal tubal 
ostium, which may- cause its complete occlusion. The thickening and 
rigidity of the ligaments and folds reduce or arrest the mobility of the 
chain of auricular ossicles (Fig. 68). The corner of the labyrinthine 
window becomes replete with connective tissue and may finally be 
obliterated. In unfavorable cases the chronic adhesive process leads to 
complete obliteration of the middle ear by connective tissue (atresia); 
in other cases, to circumscribed connective-tissue proliferations of the 
middle ear, with the result of high-grade functional disturbances, which, 
as a rule, are irremediable. The tympanic membrane itself sometimes 
participates slightly in these changes, while in other cases it is consider- 
ably involved (Plate VIII, Fig. 3). 



AFFECTIONS OF THE MIDDLE EAR 



143 




Diagnosis. — The possibility of a chronic adhesive process should 
be considered if examination with the aid of Siegle's speculum demon- 
strates reduced or inhibited mobility of the tympanic membrane. A 
chronic adhesive process may, however, also be present in cases in which 
the mobility of the membrane is well preserved, or even increased, 
owing to atrophic conditions, provided the examination shows that the 
malleus is fixed and does not participate in the movements of the tym- 
panic membrane. The air-douche sometimes gives negative results in 
highly constricted tubes, the pathological 
occlusion being so firm that the air current 
is unable to penetrate it. Application of 
the catheter reveals in many cases a tube 
of normal width, in others more or less 
pronounced stenosis or stricture of the 
tube which can be topographically lo- 
cated with the aid of bougies. 

There is suspicion of a chronic ad- 
hesive process if in a case of apparent 
middle-ear catarrh neither air-douche nor 
catheter is able to improve the hearing 
acuity even slightly. The danger of grad- 
ual spontaneous transition of simple 
middle-ear catarrh into an adhesive proc- 
ess increases with age. 

Constriction or occlusion of the 
pharyngeal tubal ostium by connective- 
tissue proliferations may render catheter- 
ization difficult or impossible. 

The functional test shows a typical 
disturbance of sound-conduction, pro- 
vided the labyrinth has remained in normal condition (see below). The 
only difference as compared to simple middle-ear catarrh is that the 
hearing acuity cannot be materially improved, if at all, by physical meas- 
ures (air-douche, catheter, aspiration, pneumomassage) . 

Prognosis and Course. — There is danger in every pathological 
connective- tissue formation of the middle ear that it will spread to 
the labyrinth. At first a network of connective tissue develops, which 
is later filled up at the basal end of the vestibular part of the cochlea 
and followed by pathological ligament formation in all perilymphatic 
spaces, with consequent atrophy of the labyrinthine nerve-ends, nerve- 
branches, and the peripheral ganglia of the cochlear nerves. Should, 
therefore, the clinical functional test show the cochlea to be in any way 
affected, coupled with reduced perception of high sounds and reduction 
of the upper sound-limit, the prognosis is absolutely unfavorable. 



Tuv Mt h Ckf 

Lateral wall of right tympanic cavity and 
membrane (Mt) in a chronic adhesive pro- 
cess. The typical mucosal folds are thick- 
ened and rigid, showing a system of path- 
ological connective-tissue layers (a) in the 
epitympanum, encircling the head of the 
malleus and completely arresting the mobil- 
ity of the latter. (Enlarged 3 : 2.) Child 
twelve years old. Pt, paries tegminis; M, 
malleus; I, incus; Ch, chorda tympani; Chf, 
fold of chorda ;h, posterior pocket of tym- 
panic membrane; v, anterior pocket of tym- 
panic membrane; Mtt, musculus tensor 
tympani; Tu, tuba auditiva. 



144 THE DISEASES OF CHILDREN 

The adhesive process with an unchanged labyrinth takes a variable 
course: benign cases experience more or less considerable and perma- 
nent improvement of the hearing acuity under timely and competent 
treatment. In other cases gradual deterioration cannot be arrested by 
any kind of treatment. 

This difference in results depends upon what kinds of adhesions 
are formed in the tympanic cavity. Strong adhesions consisting of 
connective tissue offer a less favorable prognosis than cases in which 
even more extensive connective-tissue adhesions prevail which, however, 
are elastic and well studded with nuclei. 

Treatment. — Treatment of the nasopharyngeal tract must in all 
cases precede that of the local ear affection, and the directions given 
for various forms of middle-ear catarrh in regard to nasopharyngeal 
therapy again hold good. 

Local treatment in chronic adhesive processes of the ear spells 
failure, unless preceded by appropriate treatment of the nasopharyn- 
geal tract. 

The object of conservative local treatment is to improve the posi- 
tion of the tympanic membrane, remove any secretion that may be 
present, stretch, soften, or resorb the adhesions, and thereby improve 
the impaired mobility of the chain of auricular ossicles. To obtain the 
best practical results, local treatment should commence with that part 
of the middle ear where the changes are most pronounced. 

The physical treatments consist in insufflation of air and catheteriza- 
tion, both of which may be combined with application of medicated 
vapors. Those most used are acetic ether and mixtures of acetic and 
chlorated ether (5.0 aa). Politzer recommends vapors of turpentine oil 
(oleum terebinthinse 15.0, mentholi 1.0) ; Urbantschitsch advises campho- 
rated ether (10 per cent.); Gomperz uses ammonia, for which he has 
devised a special apparatus. Application of vapors to the middle ear 
is in many cases attended with considerable and permanent improve- 
ment of the hearing acuity and a favorable effect upon the tiresome 
subjective noises. 

Injections of medicated fluids through the catheter and the tube 
into the middle ear are intended to stretch, soften, and eventually resorb 
the adhesions. They are preferably made in the dorsal decubitus, the 
correct position of the catheter in the tubal aperture having been ascer- 
tained by a test insufflation of air. In the first sittings only a few 
drops are injected, the dose being gradually increased to 0.5 c.c. The 
fluid is propelled into the middle-ear spaces by subsequent air insuffla- 
tion. The following injections have been recommended: Oleum vaselini 
sterilisatum, sodii bicarbonas (natr. bicarb. 0.5, aq. dest. 10.0, glycerini 
2.0:8-10 drops), pilocarpinum hydrochloricum in a 1-2 per cent. 



AFFECTIONS OF THE MIDDLE EAR 145 

aqueous solution, potassium iodide (pot. iod. 1.0, aq. dest. 10.0), zincum 
oleinicum (zinc, olein. 0.3, ol. vasel. 30.0 : 8-10 gtt.), zincum oleinicum 
vasogenatum, and adrenalin (sol. adren. 1.0, glycerini, aq. dest. aa 15.0). 
Many authors recommend pilocarpin in the form of subcutaneous injec- 
tions into the upper arm. A few drops of a 1 per cent, solution are injected 
with the utmost care, as even the slightest doses may produce toxic 
manifestations in intolerant patients (long-continued nausea and vomit- 
ing, collapse, weakening and continued perspiration). Latterly, fibrol- 
ysin has been applied both through the tube and subcutaneously in the 
mastoid region. Injections of fibrolysin into the tympanic cavity, how- 
ever, may very easily lead to undesirable acute inflammatory changes 
of the middle ear. 

Introduction of bougies into the tube through the catheter is indi- 
cated in tubal stenosis or stricture. The calibre of the bougies should 
gradually increase, commencing with the smallest. This treatment is 
instituted twice a week and continued for 4-6 weeks. 

If an operation on the nasopharyngeal tract has been previously 
performed, treatment with catheter and bougies should be delayed 
until the wound has completely healed, which will generally be the case 
in three or four weeks. Otherwise there is danger, in acute inflammatory 
affections or in the presence of fresh traumas, that traumatic, serous or 
purulent otitis media may result. In properly selected cases the thera- 
peutic success of the bougie treatment is excellent. However, in nor- 
mally passable cases, in which there is simply catarrh of the tube to be 
dealt with (moist crepitant rales during catheterization), mere insuffla- 
tion of air or catheterizing is the indicated treatment. 

Locally irritating fluids (weak solutions of acetic alumina, silver 
nitrate, potassium chloride, lithia carbon.) cause acute inflammation of 
the middle ear which occasionally leads to remarkable improvement 
of the hearing distance. Nevertheless, this method is not to be recom- 
mended, since it may give rise to grave suppuration of the middle ear; 
besides, the improvement is not permanent, the hearing acuity being 
reduced to its former intensity as the inflammatory manifestations 
disappear. 

A valuable therapeutic remedy is vibratory massage and rarefied 
air applied from the external meatus (Politzer). The instruments used 
for this purpose are Breitung's or Delstanche's massage apparatus. 
The latter is particularly suitable for self-application, enabling the 
patient to apply rarefied air to the external auditory duct at any time, 
relieving or arresting for the time being the most troublesome symptoms 
(subjective noises, sensation *of fulness in the ear and head, numbness). 
Massage should not be applied where it is not tolerated, causing momen- 
tary exacerbation of the complaints. 

VI— 10 



146 THE DISEASES OF CHILDREN 

Politzer points out that the treatment should not be continued too 
long and not be instituted more than two or three times a week, as other- 
wise the originally favorable results may be neutralized. The result 
after three weeks' treatment may be regarded as the best obtainable. 

The subjective complaints are also influenced in some cases by 
vibratory massage of the nasal and faucial mucosae, the external audi- 
tory duct, and concha; also by faradization of the auricular region. 

Should pneumomassage prove insufficient to mobilize the chain of 
the auricular ossicles, Lucae's pressure sound is to be recommended. 
The hollow end of the sound is filled with paraffin and applied to the 
short process after vigorous aspiration, pressure massage being con- 
tinued for J4.-1 minute. Rough movements and excessive pressure 
should be rigidly avoided. 

Strictures due to swelling of the tube can be temporarily relieved 
by injection of adrenalin solution (adren. 1.0, aq. dest., glycerini aa 1.5). 

Extreme retraction of the tympanic membrane which defies any 
other treatment can be relieved by resecting the posterior fold of the 
tympanic membrane with a narrow lancet needle, the cutting edge 
turned upward. This operation should be followed by energetic physical 
treatment (vibratory massage, aspiration). This will serve to improve 
permanently the position of the tympanic membrane and consequently 
the hearing acuity. The same result is sometimes attained by resection 
of the musculus tensor tympani (tenotomy of the tensor tendon). 

V. SIMPLE (SEROUS) ACUTE INFLAMMATION OF THE MIDDLE EAR (OTITIS 

MEDIA ACUTA SIMPLEX) 

Anatomy and Etiology. — In simple acute inflammation of the middle 
ear there are hyperemia and cedema of the mucosa, followed in a short 
time by secretion of a serous or sero-hemorrhagic exudate of the middle- 
ear spaces. Injection and swelling of the mucosa decrease in a few days, 
with subsequent complete cure, without any intervening ulceration of 
the inflammatory tissue or exudate. 

Simple as well as purulent otitis media is an infectious disease 
caused by micro-organisms, which, however, are of slight virility or quite 
degenerated. Staphylococcus pyogenes aureus, the various forms of 
streptococcus, and the influenza bacillus predominate. Cases are not 
rare in which the carefully prepared exudate shows microscopic bac- 
teria, while cultures prove negative. 

Mechanical, thermic, and chemical irritation may likewise give rise to 
simple otitis media. Introduction of irritative vapors into the middle 
ear through the tube, trauma extending to the tympanic membrane 
without destroying it, may produce the picture of a serous, though slight, 
otitis media within a very short time, sometimes within a few minutes. 



AFFECTIONS OF THE MIDDLE EAR 147 

Infection through the tube may also take place from sneezing, 
violently blowing the nose, retching or vomiting, syringing the nose, 
or aspirating water. 

In rupture of the tympanic membrane, acute otitis media may occur 
from entrance of a foreign body into the middle ear, causing traumatic 
injury to the mucosa. The exudate developing in these cases may be 
sterile, but soon becomes infected through the tube by the ever-present 
micro-organisms in the nasopharyngeal tract or through the external 
auditory duct. Persons suffering from chronic inflammatory changes 
of the nasopharyngeal tract, especially children with adenoid vegeta- 
tions, are liable to frequent recurrence of middle-ear inflammation. 
The various attacks by no means resemble each other, catarrh and 
inflammation alternating in the clinical picture (Plate VIII, Fig. 6), 
and the affection may change from simple to perforating otitis media. 

Symptoms and Course. — Simple as well as purulent otitis media 
set in with more or less sudden pain in the ear, impaired hearing, and 
fever. The pains, which may be severe in the first stage, rapidly sub- 
side. Continued severe pain, causing sleepless nights, points to purulent 
as against simple inflammation. The impairment of hearing. is of a 
medium degree (133^-27 feet C). Considerable elevation of tempera- 
ture, which recedes in a few days, is often observed in children. 

There are several degrees and forms of swelling and injection of 
the tympanic cavity, as revealed by the otoscopic examination. Thus, 
the tympanic membrane may be fleshy and thick, completely hiding 
the detailed structures including the line of the manubrium, with diffuse 
hyperemia of the entire membrane. In other cases, which by no means 
take a lighter course, the tympanic membrane is only slightly swollen 
or merely osmotic, dull, and without lustre. In these cases there is 
radial vascular injection, the red branchlets of the vesicles distinctly 
showing against the gray background of the tympanic membrane. The 
circular injection of the peripheral margin is of pathognomonic value. 

In influenza and typhoid otitis the epidermal layer of the tympanic 
membrane and the epithelial covering of the osseous auditory duct are 
often raised by vesicular formations, the vesicles having usually a bluish- 
black appearance and containing either blood-serum or a limpid yellow 
serum (Fig. 69, 1 and 2). Sometimes there are minute extravasations 
of blood, which cause the tympanic membrane, and in rare cases also 
the osseous auditory duct, to look as if sprinkled with red dots. 

The inflammatory changes of the tympanic membrane are either 
uniformly distributed over the membrane (mesotympanic type) or they 
preponderate in the upper part of the membrane, the posterosuperior 
quadrant, with the membrana flaccida, or the latter alone. In that 
case we have to deal with the epitympanic type of acute otitis media. 



148 THE DISEASES OF CHILDREN 

The functional test shows a medium obstacle to sound-conduction 
without involvement of the labyrinth, provided the hearing function 
has previously been normal. 

Course. — -The entire illness usually lasts from 8 to 10 days. The 
climax is reached in a few days, sometimes as early as the first day. 
Commencing with the third or fourth day, there are distinct signs of 
abatement of the inflammatory process, with temperature reduced to 
normal, the hearing acuity increases spontaneously, and the pains occur 
only periodically, especially in the evening and after performance of 
work which causes congestion to the head. In the following few days 
the tympanic membrane becomes paler, the pains entirely disappear, 
while the sensitiveness of the tympanic membrane persists for a few days 
longer. The patient feels the presence of his tympanic membrane, as 
if the affected ear had not yet returned to normal. Slight catarrhal 
changes may persist for some time after the inflammation has disap- 

Fig. 69. 





Formation of vesicles and sacs (prolapse) in serous (1, 2) and purulent (3-5) inflammation of the middle 
ear. 1. Vesiculation (three vesicles) in the posterosuperior quadrant. 2. Kidney-shaped vesicle of the tym- 
panic membrane. 3. Sac-like dilatation (prolapse) of the posterosuperior portion of the tympanic mem- 
brane. 4. Otitis media suppurativa acuta. Considerable swelling and bulging of the entire tympanic mem- 
brane. Mammiform protrusion of the membrana flaccida with perforation of the apex. 5. Otitis media sup- 
purativa acuta. Verrucous bulging of the posterior part of the tympanic membrane with perforation. 

peared, and the normal lustre of the tympanic membrane and normal 
hearing acuity may not return until three or four weeks later. 

The tympanic vesicles are either evacuated into the auditory canal 
by spontaneous perforation, or they are resorbed. Hemorrhages, exu- 
dates, or blood are inspissated into dark-brown coagula which gradually 
advance peripherally into the auditory canal. 

When the inflammation has run its course, the tympanic membrane 
may resume its normal condition; in some cases, however, especially in 
those which run a dragging course, striated, cloudy, or diffuse turbidity 
of the tympanic membrane, or lime deposits, will develop. The lustre 
of the membrane is thereby impaired and permanently lost. In these 
cases the fact should never be lost sight of that the visible changes of 
the membrane are accompanied by analogous changes in the mucosal 
folds of the middle ear, which may interfere with the mobility of the 
chain of auricular ossicles and tympanic membrane, giving rise to per- 
manent, though slight, disturbance of the hearing faculty. 

Treatment of the nasopharyngeal tract is absolutely necessary if 



AFFECTIONS OF THE MIDDLE EAR 149 

the inflammation, which has meanwhile run its course, was caused by 
chronic changes of that tract. This is the only possibility to prevent 
recurrence of the inflammatory manifestations, which may resemble 
the first attack, but often run a much graver course, with ulceration and 
cerebral complications. 

Diagnosis. — Based on the triple symptom-complex — pains in the 
ear, affected hearing ability, and fever — and assisted by the otoscopic 
findings, the diagnosis of acute otitis media can be made without diffi- 
culty at any stage of the disease. 

There are two affections to be considered in the differential diag- 
nosis, — acute inflammation of the tympanic membrane and purulent 
otitis media. In the former (myringitis acuta) the membrane may 
exhibit the same changes as in otitis media acuta simplex, but the stab- 
bing pains are only moderate, sometimes there is only an organic sensa- 
tion of the presence of the membrane, the temperature is not elevated, 
and the hearing acuity is almost normal. With the aid of the functional 
findings it is usually quite easy to distinguish the two affections from 
each other. 

The differentiation between simple and purulent otitis media is more 
difficult. The symptoms in both affections, notably in the first stage, 
are alike in quality and differ only in degree. Severe pains in the ear 
which rob the patient of sleep and rest point to purulent as against 
simple inflammation of the middle ear, even though the otoscopic inflam- 
matory manifestations are not pronounced and the temperature is only 
moderately elevated. Similarly, considerable impairment of the hearing 
faculty (33^-7 feet C.) occurs almost exclusively in purulent inflamma- 
tion of the middle ear, provided hearing has been normal before the last 
attack. Furthermore, high accessions of temperature favor the assump- 
tion of purulent otitis media. 

It will thus be easy in many cases to differentiate simple from puru- 
lent inflammation of the middle ear at an early stage. Other cases, 
however, will require one or two days' observation to clear the diagnosis 
and to determine whether paracentesis should or should not be done. 
Sometimes, however, it may be impossible even for the experienced 
specialist to differentiate correctly. This refers especially to infantile 
cases, where the hearing acuity cannot be exactly determined, and even 
the objective pains can only be established to a limited extent. The 
triple symptom-complex in these cases is reduced to the one sign of 
fever. Considerable elevation of temperature is an important guide for 
the diagnosis of acute purulent inflammation of the middle ear, and yet 
there are cases in which the symptom is absent in spite of the purulent 
character of the inflammation ; and in these cases, especially in nurs- 
lings, it is the long persistence of the inflammatory manifestations of the 



150 THE DISEASES OF CHILDREN 

tympanic membrane which points to the purulent nature of the proc- 
ess. The infantile tympanic membrane is thicker than that of the 
adult, in consequence of which the characteristic purulent inflamma- 
tory manifestations (circumscribed yellow discoloration of the mem- 
brane and considerable protrusions) develop much later and more 
slowly than in the adult. 

Repeated recurrence of middle-ear catarrh in older children, result- 
ing from chronic changes of the nasopharynx, sometimes cause thick- 
ening of the tympanic membrane which partly or entirely prevent the 
mucous membrane from bulging out. Doubtful cases in children should, 
therefore, be otoscopically examined several times daily, attention being 
particularly directed to variations in color and circumscribed red and 
yellow discolorations. 

Treatment. — Insertion of cotton plugs or gauze strips saturated 
with anodyne or astringent remedies, or corresponding instillations into 
the affected ear, comprise the treatment in the first stage of simple 
acute inflammation of the middle ear. The following are such remedies: 

Acid, carbol., 0.3-0.5; 

Glycer., 

Aq. dest., aa. 5.0. 

or 

Aq. carbol. (1 : 100.0), 10.0; 

Cocaini hydrochlor., 2.0; 

Atrop. sulph., 0.05. (Lermoyez.) 

or 

Olei hyoscyami, 0.8; 
Olei olivarum, 10.0. 

Also, ansesthesin in 2-5 per cent, oleic solution, or alypin 1.0, glycer., 
aq. dest. aa 15.0. Insertion of cotton tips saturated with warm adrenalin 
solution has a temporary beneficial effect. 

Acetic alumina is particularly suitable for insertion, preferably in 
the shape of gauze strips saturated with Burrow's solution 1,0, aq. dest. 
5.0, or 3^ to 15 alsol solution. These substances are less suitable for 
instillations, owing to their macerating properties. 

Application of heat (compresses of acetic alumina 1 : 10, linseed 
bags, thermophore) has a favorable effect. In other cases, again, cold 
compresses (Leiter's refrigerator) exert a better effect. Physical and 
mental rest and copious evacuations are of importance. Aspirin (0.15- 
0.5), hydropyrin (0.15-0.5), acetopyrin (0.15-0.5), and pyramidon (0.1- 
0.2) are internal remedies which may have an anodyne effect. These 
remedies, especially the first two, taken in hot lemonade or hot infusion 
of tilia flowers, are recommended at the beginning of the disease to 
produce powerful diaphoresis. Soporifics are of no use; opiates should 
be avoided, if possible. 



AFFECTIONS OF THE MIDDLE EAR 151 

The patient should remain in bed as long as the temperature is 
elevated. As soon as this returns to normal, which is usually the case 
on the third or fourth day, the involution of the process and resorption 
of the middle-ear exudate are assisted by the application of Politzer's 
air-douche. The hearing acuity is tested boch before and after air 
insufflation, and if the acuity is found to have improved, it is an exceed- 
ingly favorable prognostic sign. 

Opening of the tympanic membrane by paracentesis is indicated if 
conservative measures bring no relief, the pains continue, and the tem- 
perature does not recede to normal. The time for action is determined 
by the following considerations : Adoption of a waiting attitude without 
any definite purpose in view is not correct. The fact should always be 
kept in mind that in doubtful cases it is always better to carry out 
paracentesis than to neglect it. This minor operation, if carried out 
under such aseptic precautions as are possible in the ear, is not fraught 
with any danger. The course of simple otitis media may even be short- 
ened by allowing the serous or sero-hemorrhagic exudate to escape 
though the aperture made by paracentesis so as to render its resorption 
superfluous. It is only when paracentesis is done under unclean con- 
ditions that the danger exists of transforming a simple into an infectious 
purulent middle-ear inflammation from infection. On the other hand, 
omission of timely paracentesis may cause irremediable damage which 
may lead to severe complications and even death. 

For technical instructions to be observed in paracentesis see p. 156. 

After the inflammatory manifestations have abated and the tym- 
panic membrane is no longer hyperaemic, treatment of the nasopharyngeal 
tract must be instituted. Special attention should be given to the faucial 
tonsils in children. Should they be enlarged and the choanous passages 
interfered with, the tonsils should be removed as soon as possible. 

VI. ACUTE PURULENT INFLAMMATION (ULCERATION) OF THE MIDDLE EAR 
(OTITIS MEDIA SUPPURATIVA (PERFORATIVA) ACUTA) ; TYMPANITIS 

PURULENTA ACUTA 

Acute suppuration of the middle ear is very common in children 
and is caused by bacterial infection. The entrance of the infection is 
not always clearly demonstrable. Pyogenic factors may possibly find 
their way into the tympanic cavity through the lymph-channels without 
infecting the latter, but in most cases the infection occurs through the 
auditory tube from the nasopharyngeal tract, and the same etiological 
factors are at work which are responsible for simple inflammation of 
the middle ear The external auditory duct is only responsible for con- 
veying infection to the middle ear in traumatic suppuration. Acute 
suppuration of the middle ear in children is frequently observed in the 



152 THE DISEASES OF CHILDREN 

course of many acute affections of the nasopharyngeal tract and general 
infectious diseases. The list is headed by suppuration occurring in the 
course of acute infectious diseases, principally scarlet fever, measles, 
and typhoid, which are dreaded on account of their grave sequelae 
and complications. 

Anatomy. — In all cases in which infection of the tympanic cavity 
occurs through the tube there will be swelling of the tubal mucosa 
which soon renders the tube impassable. The swelling rapidly spreads 
to the mucosa of the middle ear and tympanic membrane ; all the middle- 
ear spaces (meso- and hypotympanum, attic, antrum, and often the 
pneumatic cavities of the mastoid process) are filled with an infectious, 
viscid or hemorrhagic exudate. Ulceration sets in very shortly, often 
within a few hours, leading to copious exudation into the middle-ear 
spaces, the pus eventually perforating the tympanic membrane and 
escaping through the external meatus. Immediately after perforation 
the secretion is often blood-tinged, especially in influenzal and typhoid 
otitis, and will become purulent only at a later stage. After the secre- 
tion has lasted for about a week, mucus will be mixed with the pus in 
the normal course of the disease, the secretion becomes stringy, the 
quantity of pus diminishes from day to day and is gradually replaced 
by mucus. When the secretion has been arrested, the aperture of the 
tympanic membrane closes in normal cases, and there will be anatomical 
and functional restoration to normal. A few weeks after healing, the 
macerated epidermal layer of the membrane in children will be desqua- 
mated, a new, normal one, with a smooth and lustrous epidermal layer, 
having meanwhile formed underneath. 

Symptoms. — The prominent symptom is violent pain in the ear, 
especially in the initial stage, which sets in suddenly and without warning. 
The paroxysms of pain often reach the highest limit, robbing the patient 
of rest and sleep. The onset of the pain is sometimes preceded by a 
sensation of occlusion and fulness in the ear and unilateral headache. 

In typical, genuine suppuration of the middle ear the hearing 
difficulty attains to a high degree (3J/£-7 feet C.) ; the acuity gradually 
returns toward the end of the affection and is perfectly normal again 
by the time the suppuration has run its course. 

There is usually considerable fever in the beginning of middle-ear 
suppuration, often reaching 104° F. and more. With the evacuation of 
pus after perforation, the temperature sinks by lysis in favorable cases. 
A sudden drop of the temperature to normal or subnormal in the first 
days of the inflammation is an unfavorable symptom, unless it is accom- 
panied by an abatement of all other pathological manifestations. Such 
drops occur in early intracranial involvement, and are sometimes ob- 
served in patients whose power of resistance has been reduced by grave 



AFFECTIONS OF THE MIDDLE EAR 153 

infections. Uncomplicated suppuration of the middle ear often sets in 
with vomiting, chills, and fever. 

Course. — The affection is conveniently divided into three stages: 

1. The initial stage, which begins with the onset of ear symptoms 
and terminates in a short time (sometimes after a few hours or at the 
most in 3 or 4 days) by perforation of the tympanic membrane and 
escape of pus from the external duct. Both pain and fever usually con- 
tinue until perforation and evacuation have taken place. 

2. The second stage is characterized by suppuration. There is no 
pain; the temperature is normal or slightly elevated. There is profuse 
secretion of pus during the first few days, which spontaneously decreases 
in about a week. Later the pus becomes string3 r , and in the last days 
the secretion consists of almost pure mucus, the secretion lasting 2-3 
weeks altogether. A thick and creamy condition of the pus and the 
admixture of large quantities of mucus increase the danger of the secre- 
tion being retained in the tympanic cavity or deep in the auditory duct, 
where it desiccates, putrefies, or decomposes. The hearing acuity im- 
proves as the suppuration decreases. 

3. The final stage sets in with the arrest of the secretion and the 
gradual filling of the perforation, which will take place in 1-2 weeks. 
Extensive perforations require more time to heal, but as long as the 
affection has run a normal course there is no danger of the gap becoming 
permanent. 

Finding of the Tympanic Membrane. — The otoscopic findings show a. 
more or less pronounced cedema and hyperemia, which may be uniformly 
diffused over the entire tympanic membrane (Plate 
VIII, Fig. 7). In other cases the membrane is 
more inflamed and swollen in some places than in 
others, where hyperemia, cedema, and protrusion 
are particularly pronounced. Extensive vesicle 
formation is not rare (Fig. 69). In middle-ear 
suppuration of the epitympanic type (Kuemmel) Acute purulent inflammation 

,i • n i •!•!,• t-.i.;i of the middle ear during influ- 

the inflammatory mamiestations are limited to the enZ a. Three hemorrhagic ves - 
upper part of the tympanic membrane (PI. VIII, gST™ the tympanic mem ' 
Fig. 5), Shrapnell's membrane, and the postero- 

superior quadrant (Fig. 69, 3-5), and not infrequently lead to wart-like- 
eminences of the posterosuperior quadrant. 

The intensely red color of the tympanic membrane, however, is 
not a reliable indication of the gravity of the middle-ear inflammation, 
as the membrane may show a deep-red color and considerable swelling 
in simple inflammation of the middle ear and even in myringitis. The 
line of the manubrium is entirely hidden by the swelling. The tympanic 
membrane may even assume a deep-red coloration in light degrees of 




154 THE DISEASES OF CHILDREN 

otitis media in the course of influenza, and the epidermal layer may be 
raised by blisters. On the other hand, the membrane may be pale red 
even in the presence of considerable accumulation of pus in the middle 
ear, or there may be only a radial and peripheral vascular injection. 
Generally speaking, the intensity of the reddening and swelling of the 
tympanic membrane decreases but little with the progressive purulent 
transformation of the exudate. If no perforation takes place and the 
acute inflammation leads to empyema of the middle-ear spaces, espe- 
cially to empyema of the tympanic cavity, the membrane may be opaque, 
grayish-yellow, with but a slight injection of the radial vessels. 

Imminent perforation is usually indicated by circumscribed yellow 
discoloration and considerable bulging of the membrane. After per- 
foration there is either a freely passable, visible, more or less circular 
gap or a fissure, the swollen margins of which lie close together, so that 
the aperture is only just large enough for the pus to escape. Removing 
the secretion with swabs may render the perforation invisible, and it is 
only recognized by the further escape of pus; it may, however, also be 
localized by aspiration with Siegle's speculum. The aperture is some- 
times located at the apex of an eminence. 

The size of the perforation varies. Comparatively large apertures 
with extensive destruction may cause fulminating suppuration of the mid- 
dle ear in the course of acute infectious diseases, especially scarlet fever. 

The findings of the membrane and the mucosa of the tympanic 
cavity in the advanced stages of suppuration resemble each other in 
regard to reddening and swelling as well as osmosis. Finally the swelling 
of the membrane is abated and the epidermal layer dries up. The per- 
foration is now distinctly visible, even in cases where such was impos- 
sible before. The margin of the perforation is at first still thicker than 
the surrounding membrane, but is finally deflated. During the healing 
process it is colored grayish- white. 

The functional test of the auditory duct in all uncomplicated cases 
shows considerable disturbance of sound-conduction, and the hearing 
acuity is considerably reduced at the beginning of the inflammation. 
Great pressure of the secretion is evidently able at this time to cause 
slight spontaneous nystagmus (bilateral with lateral vision) ; it disappears 
as perforation occurs. 

Diagnosis. — Based upon the history and the characteristic symp- 
toms (severe sudden pain in the ear, impairment of hearing, findings of 
the tympanic membrane), the diagnosis of purulent otitis media can be 
made without difficulty in the first stages of the affection. 

For the differential diagnosis there is only simple middle-ear inflam- 
mation to be considered. Great swelling of the tympanic membrane, 
bulging of the posterosuperior quadrant, and especially the circumscribed 



AFFECTIONS OF THE MIDDLE EAR 155 

yellow discoloration, with considerable impairment of hearing (provided 
there has been normal acuity previously), point to suppuration as against 
simple inflammation of the middle ear. The same refers to persistent 
pain with periodical severe exacerbations. In paroxysmal pain alter- 
nating with perfectly painless intervals, however, simple middle-ear 
inflammation is more probable. High fever points to purulent inflam- 
mation of the middle ear. In nurslings and children up to eight years 
of age it is, of course, impossible to test accurately the hearing acuity; 
but testing with alarm instruments or well-known noises, such as strik- 
ing a gong or glass, rattling with keys, high-pitched tuning-forks, will 
usually establish an approximate determination. In certain cases thor- 
ough examination of the antrum (transillumination, X-ray examination) 
will render valuable service. 

Considerable pain which patients are apt to refer to the ear occurs 
in young children in late teething, acute inflammation of the pharyngeal 
lymph-glands, tonsillitis, and swelling of the faucial tonsils. Sometimes 
intense earache occurs as a prodromal symptom of an acute infectious 
disease, usually following an affection of the nasopharyngeal mucosa. 
In the period of puberty, violent earache resembles the signs of a begin- 
ning otosclerosis, although the otoscopic findings are negative. 

In the suppurative stage the odorless, profuse, pulsating secretion, 
and later the odorless pus mixed with mucus, point to middle-ear sup- 
puration as against otitis externa. In the simultaneous presence of 
abscesses of the auditory duct (otitis externa furunculosa) it may be 
difficult to decide at the first examination whether there is simply an 
inflammation of the auditory duct or a middle-ear suppuration besides, 
especially if there is a multiple furunculosis of the external duct with 
considerable secretion of pus. 

The following points hold good in regard to differential diagnosis: 

1. Otitis externa runs an afebrile course both in older children and 
adults, while in young children there is sometimes moderate elevation 
of temperature. Thus, if it is found from the history in doubtful cases 
that the affection has set in with high fever, there is a probability of the 
simultaneous presence of middle-ear inflammation. 

2. After cleansing the auditory duct in otitis externa and rendering 
it permeable by the insertion of a thin ear-speculum, there will be normal 
or slightly reduced hearing distance, provided the tympanic membrane 
is not too much impaired from a macerated epidermis. In the simul- 
taneous presence of middle-ear suppuration, however, the hearing acuity 
will not improve even after rendering the auditory duct permeable. 

3. The osseous part of the auditory canal is an important guide in 
children over four years of age. Otitis externa is always confined to the 
membranous part of the canal, so that the osseous part will be found of 



156 THE DISEASES OF CHILDREN 

normal width and the tympanic membrane unchanged on inserting the 
ear-speculum through the stenosed part of the canal. If, on the other 
hand, there is middle-ear inflammation, and stenosis of the canal due to 
involvement of the antrum and mastoid process, inspection of the osseous 
part will reveal a settling of the posterosuperior wall and more pronounced 
swelling of the membranous than the osseous portion. 

Treatment of Acute Suppuration of the Middle Ear. — In the first 
stage of the affection the treatment should be local and purely symp- 
tomatic. 

Severe earache is sometimes relieved by instillation of 3-5 per cent, 
carbolglycerin, solutions of anaesthesin and adrenalin. Hot solutions 
(104° F.) of acetic alumina or 1 per cent, alsol may be instilled in spacious 
ducts in which the resultant epithelial maceration will probably cause 
no constriction. Instillation of cocaine, novocaine, or alypin solutions 
may have a very good, though only temporary, effect. A cotton tip 
saturated with a 20 per cent, solution is inserted up to the tympanic 
membrane. Local application of cold (ice-bag, Leiter's apparatus) is 
likewise indicated in the first stages of the inflammation. Withdrawal 
of blood is usually without effect. Rest in bed and copious defecation 
are essential. Alcoholic beverages and strong tea or coffee are to be 
avoided. 

In considerable pain and fever all anodyne remedies will soon lose 
their effect. In these cases it is advisable not to wait for spontaneous 
perforation, but to perform paracentesis without delay. This simple 
operation is done with the lancet-needle fixed in Politzer's handle. The 
tympanic membrane is incised from below upward to the umbo. If 
circumscribed yellow coloration of the membrane indicates imminent 
perforation, paracentesis should be made at that place, or at least includ- 
ing it, as otherwise there is danger of an unsuccessful operation. 

Preparation for Paracentesis. — The concha is cleansed with a cotton 
tip saturated with benzine, the head is covered with a fenestrated sterile 
compress, the concha being pulled out through the aperture. The 
external meatus is cleansed with 6 per cent, peroxide of hydrogen. Instil- 
lation of a novocaine-adrenalin solution is to be recommended for induc- 
ing anaesthesia, 1 c.c. of a 20 per cent, novocaine or alypin solution, 
heated to 104° F., being added shortly before use to 5 drops of the heated 
adrenalin solution (commercial). The fluid is allowed to remain in the 
external duct for 10-15 minutes. The Freiburg Ear Clinic recommends 
the injection of a Schleich-adrenalin mixture into the tympanic cavity. 

Instillation of a 5-10 per cent, aqueous cocaine solution, with an 
addition of 5 drops adrenalin solution, 1.0 : 1000, has also been recom- 
mended. Eucaine (8 per cent, aqueous solution) is non-toxic and ster- 
ilizable. The following should also be mentioned: Gray's solution 



AFFECTIONS OF THE MIDDLE EAR 157 

(cocaine muriat. 0.5,- ol. anil., alcohol absol. aa 5.0 : 10 drops, heated 
to 104° F., are allowed to remain in the auditory duct for about 5 min- 
utes); Haug's solution (cocain. muriat. 1.5-3.0, aq. dest., glycer. aa 10.0, 
alcohol absol. 10.0). 

The operation should be made under aseptic precautions to avoid 
the danger of secondary infection. If paracentesis is done at the proper 
time, it will be followed immediately by a sero-hemorrhagic or a hemor- 
rhagico-purulent exudate. Immediate evacuation of pure pus shows 
that the operation was done too late, that the inflammatory exudate 
has been completely transformed into pus, and that all middle-ear 
spaces are replete with pus (acute empyema of the middle ear). Gauze 
strips, prepared with hot acetic alumina or 1 per cent, alsol, should be 
held in readiness for immediate insertion into the auditory meatus 
after paracentesis, without resorting to drying or syringing. A moist 
ear compress follows, and the patient is put to bed. In favorable cases 
there is profuse purulent secretion from the external meatus in the course 
of the next few hours. The temperature gradually recedes to normal in 
from 3 to 5 days; the pain usually disappears completely a few hours 
after paracentesis. 

If the perforation is not located on the level membrane, but at the 
apex of an eminence, there may be purulent stagnation leading to tem- 
porary agglutination and retention. In these cases a liberal incision 
of the eminence with the lancet-needle is the indicated treatment. 

Commencing purulent secretion marks the second stage of the 
affection, and the only thing to do now is to keep up the evacuation of 
pus and prevent its retention or stagnation. This is accomplished in 
two different ways. First, moist compresses of acetic alumina or 2 per 
cent, alsol are applied and renewed in 24 hours. A moist gauze com- 
press is introduced into the external meatus for purposes of drainage, 
and after 24 hours all the layers of the compress are usually saturated 
with pus. Later hydrophile or antiseptically impregnated gauze strips, 
4-6 cm. long and 2 cm. wide, are inserted (xeroform, iodoform, dermatol, 
aristol, ectogen). A nurse can attend to the renewal of the gauze strips, 
using straight or geniculate forceps with blunt points, which are cleansed 
with benzine and sterilized by boiling both before and after use. The 
strips have to be renewed at regular intervals : in extensive secretions every 
one or two hours, in slight secretions two or three times a day. The 
strips should not be allowed to remain in the ear when no longer able 
to absorb secretion; as soon as a strip is saturated, it has to be removed 
before the secretion behind has had a chance to stagnate. A sign of 
sufficiently frequent renewal of the strips is the presence of very little 
pus in the external meatus upon removal of the strips, and the fact 
that the patient is free from pain and experiences a free sensation in the 




158 THE DISEASES OF CHILDREN 

external duct. Irrigations are not required in perfectly normal cases; 
but when the secretion is dry and tough, sterilized water of a temperature 
of 100°-104°F. should be used. Insufflation of antiseptic powders is 
quite superfluous, especially where the secretion is copious, 

This method of treatment also has the advantage of keeping the phy- 
sician informed on the condition of the suppuration, although he may not 
see the patient daily, the decrease in the amount of secretion being shown 
by the gauze strips becoming less saturated and finally remaining dry. 
In the normal course, the purulent secretion becomes more viscous at the 
end of the first week, and a few days later stringy, since the mucoid pus 
has a tendency of depositing itself in the tympanic cavity or external 
duct. At this period application of peroxide of hydrogen is indicated 

(3-6 per cent, solution of hydrogen 
peroxide, or perhydrol 5.0 : aq. 
' i\ dest. 30.0), which is instilled into 
the ear 3 or 4 times daily at a tem- 
perature of 1 04° F. The pus is now 
X*X>^ removed from the tympanic cavity 

1 2 3 3 or 4 times a week by air insuffla- 

r^J^r^^^^n^^J^T^ tion, followed by cleansing of the 
ST^^eTySrnicteSnr 1 (6xating) Ume de ' external duct with sterile cotton 

tips and 5 per cent, aqueous perhy- 
drol solution. The hearing acuity usually rapidly increases under the 
influence of air insufflation, and undergoes a temporary reduction only 
when the middle-ear spaces are again replete with secretion. Aspiration 
of the secretion by careful rarefaction of air in the external duct with 
Siegle's speculum or an aspirating bulb may be serviceable. Great care 
and attention should be devoted to the external ear, since an additional 
eczema or inflammation of the auditory duct will favor the pus stagnation 
in the middle ear. In the last stages of the secretion, insufflation of air 
should be resorted to daily until the hearing acuity remains permanently 
on a satisfactory level and the lateral surface of the tympanic membrane 
has lost its hypersemic appearance and become dry. The gauze inserts 
are continued until the perforation is completely closed. After the arrest 
of the secretion, the perforation gap usually closes within a few days, 
the first sign being white coloration of the margin by the young, newly 
growing epidermis. 

While the gap closes, it becomes gradually smaller. The new growth 
of tissue occurs almost exclusively from the central part of the tympanic 
membrane to the periphery. Local treatment in this stage is to be 
deprecated. The perforation closes quite spontaneously, and the tym- 
panic membrane as well as the hearing acuity becomes normal again. 

Middle-ear inflammation which has persisted for a long time may 



AFFECTIONS OF THE MIDDLE EAR 159 

be followed by scars of lime deposits in the tympanic membrane (Fig. 
71). After the middle-ear suppuration has run its course, it is advisable 
to keep the external meatus closed for several weeks by a small cotton 
tampon. 

In order to prevent recurrence of middle-ear inflammation or ca- 
tarrh, it is necessary to treat the nasopharyngeal tract and to institute 
therapeutic measures to ensure permeability of the choanse and naso- 
pharynx as well as to care for restitution of normal conditions of the 
pharyngeal openings. 

VH. ACUTE INFLAMMATION OF THE MIDDLE EAR IN INFANTS AND YOUNG 
CHILDREN (ACUTE INFANTILE OTITIS) 

Otitis media of the nursing period has latterly received close at- 
tention by Gomperz. Valuable contributions on this frequent affection 
have also been contributed by Aschoff, Politzer, Preysing, and S. Weiss. 

The occurrence of otitis media in infancy is principally favored by 
the anatomical conditions of the infantile auditory duct. The great 
frequency of infantile otitis is explained, according to Gomperz, by the 
following etiological factors: (1) The tubal ostia open into the naso- 
pharyngeal space; (2) the changes in the circulation following birth, 
together with hyperemia and loosening of the tympanic mucosa; (3) 
persistence of the embryonal character of the middle-ear mucosa beyond 
the fetal period; (4) immaturity; (5) hereditary constitutional affections, 
such as scrofulosis, tuberculosis, syphilis, rhachitis, and descent from 
alcoholic parents; (6) traumatic injury of the middle ear before and 
during birth, entrance of amnion or its constituents into the middle ear; 
(7) infectious diseases, especially la grippe, less frequently measles, 
pertussis, varicella, diphtheria, scarlet fever, in the course of which 
coughing, sneezing, crying, and vomiting lead to infection of the middle 
ear; (8) haematogenous infection; (9) gastro-intestinal and cerebral affec- 
tions, which lead to infection of the tympanic cavity from vomiting. 

The tympanic cavity of infants contains abundant mucous tissue 
and plenty of fluid in the first few weeks of life. Both are excellent cul- 
ture grounds for invading bacteria. The myxomatous tissue is subject to 
very rapid purulent transformation, and, as there are vast accumu- 
lations of it in the upper tympanic cavity, epitympanic suppurations in 
infants and young children are of frequent occurrence and by no means 
devoid of danger. During the same period the middle-ear spaces are 
not freely permeable. The epitympanum and the upper part of the 
mesotympanum are infiltrated with connective-tissue bridges and muco- 
sal septa; the folds of the mucosa are extremely thick and succulent; 
the antrum contains plenty of mucous tissue in the first weeks of life; 
and thus it comes to pass that with the onset of an infection a large 



160 THE DISEASES OF CHILDREN 

number of disseminated small inflammatory foci will develop in the 
tympanic cavity. These inflammatory foci partly intercommunicate 
and are partly isolated and segegated by the mucosal septa. Under 
these circumstances there is very little chance for early and convenient 
escape of the pus, once purulent transformation has begun. It is only 
after fluidification of the entire mucous tissue of the middle ear and after 
formation of a true empyema of the tympanic cavity that spontaneous 
drainage can be hoped for. Up to that time extensive swelling and deep 
ulcerations of the middle-ear mucosa will develop. The occurrence of 
characteristic papillary proliferations of the inflamed mucosa of the 
middle ear has been established by Politzer. 

The Eustachian tube of the new-born is remarkably short and wide, 
and the muscles are feebly developed. Nor can it be definitely denied 
that in some cases the Eustachian tube is not completely closed at birth. 
It is through all these conditions that infection of the infantile middle 
ear on the part of the pharynx is particularly favored. It may easily 
happen that the mucus present in the pharynx, aspirated fluid, etc., 
may enter the tympanic cavity of infants by deglutition and vomiting. 
In many cases otitis may occur from the fact that the penetrated mucus 
is at the same time the carrier of the infection; in other cases the mucus 
entering into the middle-ear spaces may act as a foreign body, causing 
as such an inflammation which is changed into ulceration by secondary 
infection from the pharynx; indeed, many authors look upon infantile 
otitis as an affection due to the entrance of foreign bodies. 

Suppuration is further favored by the fact that debilitated infants, 
who are particularly liable to infection, suffer from impaired respira- 
tion and deglutition, and that in tender and anaemic children accumu- 
lation of mucus or food remnants in the pharynx cannot be avoided. 

One of the principal causes of the frequent occurrence of middle- 
ear inflammation in infants and young children is the frequency of 
faucial and tubal affections. Furthermore, the recumbent position of 
nurslings is to be taken into account, as it favors irritation of the tube 
and consequently the middle ear in disturbed deglutition or respiration, 
and at the same time fluids, coagulated milk particles, etc., may enter 
the tympanic cavity. Furthermore, there seems to be a possibility that 
in infants and young children up to the age of two or three years, who 
suffer from a serious affection, there occurs spontaneous suppuration of 
the mucous tissue in the middle ear owing to general debility and anae- 
mia. In these cases the micro-organisms which are always present in 
the nasopharyngeal tract, but cannot bring about a purulent inflam- 
mation in a healthy child, may lead to suppurative decomposition of 
the mucous tissue of the tympanic cavity, which is an easy prey to 
infection and purulent transformation, as explained above. This also 



AFFECTIONS OF THE MIDDLE EAR 161 

explains why, in autopsies on infants who died during the first month 
of life up to the end of the first year, suppurative exudates are often 
found in the tympanic cavity, and why the histological examination of 
these cases admits of distinct demonstration of acute inflammatory 
changes of the mucous membrane. Abundant inflammatory foci are 
especially found in the mucous tissue accumulated at the fundus of 
the tympanic cavity and in the attic. 

The healthy tympanic cavity is germ-free, according to the inves- 
tigations of Preysing and S. Weiss. Infantile otitis is caused in the 
majority of cases by the pneumococcus. 

Symptomic Peculiarities in Infantile Otitis. — The most important 
point is that in infants and young children there may exist not only 
catarrhal affections, but also purulent inflammation of the middle ear, 
with apparently light (or without any) symptoms, in spite of serious 
conditions. Besides there is the danger that fever, the most constant 
prodromal symptom of acute inflammatory affections of the nasopharyn- 
geal and respiratory tracts, is not referred to the ear, but erroneously 
to affections of the tracts mentioned. Gomperz rightly recommends 
examining the ears of infants and young children in all febrile affections, 
even in the absence of ear symptoms. 

The possibility of overlooking an inflammation or even suppura- 
tion of the middle ear is increased by the helplessness of the infant. It 
is not before the fourth month that infants direct attention to the pos- 
sibility of an auricular affection by rubbing the ear, putting the hand 
to the head, crying whenever the ear or its vicinity is touched, and 
even avoiding to lie down on the affected side. Exacerbation of the 
pain in the ear during sucking often interrupts the feed, the infant 
giving vent to crying. Up to that age, however, all motor reaction 
may be absent, and attention is aroused only by the occurrence of puru- 
lent secretion. This, however, occurs at a comparatively late stage, 
the tympanic membrane of the new-born being thicker and more resis- 
tant than that of the adult. Sometimes it takes as long as one or two 
weeks for the tissue of the tympanic membrane to become ulcerative, 
causing perforation and evacuation of the pus through the external 
meatus. Furthermore, the late occurrence of perforation is favored by 
the fact that the permeable tympanic cavity at that age does not rep- 
resent a uniform space, so that time is required for a sufficiently large 
quantity of pus to accumulate which is capable of powerfully bulging 
out the tympanic membrane, stretching the tympanic tissue, and thus 
accelerating the purulent transformation and perforation. The latter 
may also be delayed or frustrated by the pus escaping into the pharynx 
through the short and ample tube. 

I observed the case of a girl, 12 years of age, with a chronic sup- 

VI— 11 



162 THE DISEASES OF CHILDREN 

puration which had existed for years. The tympanic membrane had 
never been perforated and revealed nothing but two intermediary lime 
deposits; evacuation of the pus occurred spontaneously and without 
trouble into the pharynx through the Eustachian tube. 

Suppuration of the middle ear occurs less frequently in breast-fed 
than bottle-fed infants. There is sometimes danger of otitis in breast- 
fed infants from unsuccessful sucking if both nares are occluded by pres- 
sure from the mother's breast and milk particles enter the tympanic 
cavity in swallowing. 

Owing to congenital cracks of the osseous facial canal, there is 
greater danger in infantile otitis than in otitis media of the adult, of 
peripheral paralysis of the facial nerve, due to spreading of the inflam- 
mation to the connective tissue enveloping the nerve; but any such 
paralysis is only slight and will disappear in a few days or, at the most, 
two or three weeks. Faradic excitability is nearly always preserved, and 
there is no degenerative reaction. 

I am unable to share the opinion that otitis runs a more fulminat- 
ing course in robust than in under-nourished and debilitated children, 
and that the perforation in the former occurs rapidly and in the latter 
slowly or not at all. The fact that at autopsy pus has been frequently 
found in the middle ear of infants, but rarely a perforation, may be 
explained in this way, that otitis in these cases developed during agony, 
so that there was no time for perforation to take place. Besides, in a 
number of these cases the suppuration of the middle ear seems to be of 
a tuberculous nature, and delayed perforation under these circumstances 
also occurs in adults. 

An extremely characteristic symptom of acute infantile otitis is 
the sudden onset of fever, in which the temperature reaches the highest 
possible degrees in the first few days. Temperatures up to 104° and 
106° F. are by no means rare. The fever is of the continuous type, and 
return to normal or subnormal temperature is usually a sign of compli- 
cations. 

In the first days of serious inflammation of the middle ear, chills 
and fever, sometimes accompanied by vomiting, will occur just before 
perforation. Apparently meningitic symptoms may likewise set in, 
such as collapse manifestations, stupor, lagophthalmos, nasal respira- 
tion, sudden unrest, epileptoid movements of the extremities, crying out, 
disturbed sleep, or sleeplessness. Ortner has summarized this symptom- 
complex under the name of "meningism." These grave manifestations 
sometimes disappear after spontaneous perforation or paracentesis, as 
soon as the pus commences to escape. Should they occur while purulent 
secretion is already established, it is the first sign of positive meningitis 
with unfavorable prognosis. 



AFFECTIONS OF THE MIDDLE EAR 163 

Peculiarities of the Course of the Affection. — A few important 
points may be mentioned. Purulent secretion may occur later in infants 
and young children than in adults, but may also last much longer. This 
does not signify a disturbed course, nor give rise to apprehension, unless 
there are objective signs of an involvement of the mastoid process. This 
is in many cases due to the fact that inflammation of the middle ear 
preferably attacks debilitated, under-nourished, rhachitic, or otherwise 
affected children, especially those who have been weakened from acute 
infections and recovered but slowly. 

A particularly unfavorable symptom of infantile otitis is abundant 
granulation of the middle ear and of the perforation margin of the tym- 
panic cavity, which may occur at an early stage. This condition may 
interfere with free evacuation of the pus from the middle ear, causing 
it to be retained in the middle-ear spaces; sometimes the secretion is 
completely arrested. Such retention is always associated with recur- 
rence or exacerbation of the local pains and elevation of temperature, 
together with a further decrease of the hearing acuity. 

A further peculiarity of infantile otitis consists in the great danger 
of abscess formation in the pars mastoidea, which is favored by the 
relatively large antrum being but loosely connected with the tympanic 
cavity, and by the plethoric diploic bone of the pars mastoidea in in- 
fants and young children. These abscesses very rapidly perforate 
outward, forming a subperiosteal mastoid abscess, the lateral wall of 
the antrum being a very thin osseous layer which often contains carti- 
laginous remnants in rhachitic children. The cartilage rapidly ulcerates, 
a fistula resulting at the lateral surface of the pars mastoidea and under- 
neath the periosteum. 

Finally, it is not surprising that tuberculous suppuration of the middle 
ear, which is not rare in infancy and childhood, sets in without symptoms 
and may remain undiscovered for a considerable time. This condition pre- 
vails to a certain extent even in adults, and is only accidentally noticed 
when pus exudes from the ear or impaired hearing makes itself felt. 

The resorptive properties of the infantile mucosa of the middle ear are 
unquestionably greater than those of the adult, and comparatively exten- 
sive exudates may still be resorbed in the various stages of infantile otitis. 

Tabes mesenterica which is sometimes associated with otitis media 
has been divided by Preysing into two groups: (1) that attributable 
to the respiratory tract and (2) that attributable to the intestinal tract. 
He does not believe, however, that this affection results from aspiration 
or escape of the secretion from the middle ear into the respiratory or 
intestinal tract, but rather that it is due to toxic substances which have 
found their way into the blood and lymph currents owing to rapid re- 
sorption from the middle-ear empyema. 



164 THE DISEASES OF CHILDREN 

Otoscopic Examination and Findings. — Formerly many authors 
considered otoscopic examination of the infantile tympanic membrane 
to be impossible, and we are indebted to Gomperz for having demon- 
strated the possibility of methodic otoscopy of infants. He devised a 
set of 5 particularly short ear-specula of %, 1, 2, 3, and 4 mm. in di- 
ameter, respectively, for irrigation of the infantile ear, the cannula being 
covered by a short draining tube. 

Cleansing the external auditory duct from scales or cerumen has 
to be done most carefully, the infant's head being held perfectly quiet. 
After insertion of the speculum, the otoscopic examination can be facili- 
tated by pressing it downward toward the base of the auditory duct. 
It should be remembered that the infantile duct consists only of the 
membranous part, that it becomes narrower as it approaches the tym- 
panic membrane, and only widens in a kind of fissure immediately 
before the membrane. The latter inclines considerably outward, so that 
its posterosuperior part is closer to the eye of the examiner than the 
anterior section to an even greater degree than is the case in adults. 
Gomperz also states that the infantile tympanic membrane assumes a 
pink tint while the infant is in the act of crying. 

Blood extravasations of the tympanic membrane are no less fre- 
quent than in adults. In considerable cedema of the epidermal layer 
the tympanic membrane has at times a pale-red (grayish-red) tint, even 
in the presence of considerable inflammation. Occasionally several 
eminences are visible. The line of the manubrium is entirely absent. 
Blood vesicles can often be observed in the initial stages of influenza 
otitis. After perforation has set in, especially in the posterosuperior 
part, wart-like or conical protuberances are by no means rare. The 
margins of the perforation are usually considerably swollen, with the 
result that the perforation can be recognized as a gap on outflow of 
pus or aspiration. Occasionally granulations develop at the margin of 
perforation in the course of a few days, with polypoid protrusions 
toward the external duct. As is the case in the adult, profuse sup- 
puration is followed later by a mucous secretion. With the arrest of 
the secretion the gap usually closes within a few days, while the gran- 
ulations at the margin of perforation undergo spontaneous involution in 
proportion to the quantitative diminution of pus. Operative removal 
of the granulations is only necessary when the healing process takes a 
dragging course. 

The difference in the otoscopic findings between otitis with acute 
infections, and tuberculous otitis media, has been discussed in the chap- 
ter on the Diseases of the Ear and Acute Infectious Diseases. 

Diagnosis, Prognosis, and Course. — With painstaking observation 
of the patient and careful otoscopic examination, there can be no dif- 



AFFECTIONS OF THE MIDDLE EAR 165 

ficulty in the diagnosis of infantile otitis, provided the podiatrist con- 
siders the possibilities of otitis media in infants and young children at a 
sufficiently early stage. The prognosis should be made cautiously. 
Relatively slight hyperemia of the tympanic membrane in infants by 
no means excludes the purulent character of otitis media. After com- 
plete development of an empyema of the middle ear, the fever may 
abate or entirely disappear without perforation of the membrane, but 
spontaneous perforation may still occur later. It is advisable, there- 
fore, to postpone the decision of the prognostic question, as to whether 
a perforation is to be expected or not, until either the tympanic findings 
definitely indicate the imminent perforation (circumscribed red or 
yellow coloration) or the involution of the inflammatory manifestations 
is recognizable by a rapid reduction of the swollen membrane. 

The prognosis is favorable in otherwise robust, well-nourished 
infants for both simple and suppurative otitis media. The organ will 
be completely restored without any impairment of the hearing acuity. 
In genuine inflammation of the middle ear and in otitis developing in 
the course of common colds (coryza, bronchitis, etc.), a permanent 
aperture need not be apprehended. 

In debilitated, anaemic, under-nourished, rhachitic infants there is 
some danger of acute otitis media developing into the chronic form, and 
in the most favorable contingency into healing at a later period, but with 
permanent changes remaining. This is particularly to be apprehended 
if the initial stage of suppuration has escaped attention or has been 
neglected. When the suppuration has become chronic, it soon leads to 
moist eczema and constriction of the auditory duct, with consequent 
retention of pus in the middle ear, ulcerous processes of the mucosa, 
formation of granulations and polypi, carious changes of the auricular 
vessels and osseous walls of the middle ear, with all their sequelae. 

The prognosis is unfavorable in tuberculous infantile otitis and 
ulcerations of the middle ear caused by the streptococcus mucosus. 
Endocranial involvement is rare in infantile age, probably owing to 
the fact that, after involvement of the mastoid, outward perforation 
underneath the periosteum occurs more rapidly than in older children 
or adults. 

The treatment of infantile otitis hardly differs from that of otitis 
media in adults. Early paracentesis is important, as its omission may 
be responsible for the sudden development of a grave cerebral symptom- 
complex (meningism), or suppurative meningitis. The auditory duct 
requires the greatest care; the skin should be repeatedly anointed and 
the lumen kept free by thorough removal of the secretion and the mac- 
erated epithelial masses which accumulate in the form of small scales. 
Constriction or occlusion of the auditory duct by eczema, inflammatory 



166 



THE DISEASES OF CHILDREN 



processes, etc., may considerably hinder the treatment and cause re- 
tention of the secretion, with incalculable consequences. In a protracted 
course repeated paracentesis is advisable. Extensive granulations may 
be removed at an early period; should they be allowed to remain, the 
inflammation will usually take a longer course and may even become 
chronic from proliferation of granulations. After the inflammation of 
the middle ear has been cured, it is often necessary to remove the con- 
siderably enlarged palatal and faucial tonsils to prevent recurrence of 
the inflammation. 



VIII. ACUTE PURULENT 



MASTOIDITIS (OSTEOPERIOSTITIS 
PROCESS) 



OF THE MASTOID 



Anatomy. — The anatomical changes in acute mastoiditis depend 
upon the kind of infection, the duration of the illness, and the normal 
anatomical conditions of the mastoid process. The beginning of the 
inflammation is marked by hypersemia of the mastoid mucosa and the 
inflammatory thickening of the soft covering of the mastoid process 
(lateral wall of the mastoid and posterosuperior wall of the osseous 

auditory duct) . The blood-vessels are con- 
siderably distended. Ulcerative transfor- 
mation of the inflammatory exudate and 
abscess formation occurs as the inflamma- 

Fig. 73. 



Fio. 72. 





Acute mastoiditis with suppuration in a mas- 
toid air-space. Boy twelve years old. 



Acute mastoiditis (diploic mastoid) . Boy six years old. 
o, normal bone; i, inflammatory infiltrate; a, pus. 



tion proceeds. This condition leads to empyema in a pneumatic mastoid 
(Fig. 72) . The various cells become replete with pus, which soon extends 
over all mastoid cavities corresponding to the normal intercommunication 
of the mastoid cells. Purulent decomposition of the osseous septa and for- 



AFFECTIONS OF THE MIDDLE EAR 



167 



Fig. 74. 




Typical cleft of 
the external audi- 
tory duct and de- 
scending postero- 
superior wall of the 
duct (a) in acute 
purulent mastoi- 
ditis. 



mation of a confluent abscess filling the entire mastoid process will develop 
later, usually in a few weeks. In diploic mastoids small disseminated ab- 
scesses, from millet-seed to hemp-seed size (Fig. 73), will develop first, the 
diploic tissue soon becomes ulcerative, and the final result is again a large 
abscess. As early as the end of the first week granulations will commence 
to develop in the abscess cavity or mastoid cells, as the 
case may be, which will steadily increase; the walls of old 
abscesses are sometimes completely covered with granu- 
lations. 

Occasionally there is spontaneous healing of the ab- 
scess by resorption or escape of the pus into the tympanic 
cavity through the antrum and thence outward through 
the perforation aperture. The extension of the suppura- 
tive inflammation of the mastoid to the squama and the 
zygomatic process is discussed on page 281. 

Perforation of the abscess through the walls of the 
mastoid process is, however, of far greater frequency. 
If it occurs through the lateral wall, a localized sub- 
periosteal abscess will develop in the mastoid region 
(Figs. 76, 77) ; if through the anterior wall, purulent infiltration of the 
integument of the auditory canal with eventual perforation into the 

canal will be the result. 

In tuberculous abscesses it is not a rare 
occurrence for the auditory duct to be 
surrounded by pus, and for the abscess 
eventually to perforate through the an- 
terior wall of the duct at the fusion of the 
os tympanum with the membranous part 
of the duct or through the gap of ossifi- 
cation of the os tympanum toward the 
sub-maxillary articulation. The final 
result in these cases may be purulent in- 
flammation of the articulation. 

Downward perforation of the abscess 
will cause descending abscesses to de- 
velop, the various forms of which may be summarized under the generic 
name of Bezold's mastoiditis. 

As the pus finally advances through the medial wall of the mastoid, 
it will lead to endocranial involvement (pachymeningitis externa, extra- 
dural abscess, etc.). 

In the early stages of mastoiditis the interior of the mastoid is 
considerably more affected than the periosteum; acute tuberculous 
mastoiditis, however, usually runs its course under the picture of osteo- 



Fig. 75. 




Descending posterosuperior wall of the 
auditory duct (a) and cleft-like constriction 
(6) of the duct in acute suppuration of the 
antrum and pars mastoidea in a child three 
months old. 



168 



THE DISEASES OF CHILDREN 



periostitis, the first symptom principally involving the periosteum with 
early granulation of the periosteal part confronting the bone. 

The consistency of the pus contained in the mastoid depends upon 
the infection and time of the primary illness (middle-ear suppuration). 
In streptococcus and staphylococcus infections the pus is yellow and fluid ; 
in tuberculous infections it is exceedingly thin or even watery, greenish- 
yellow, and infiltrated with thick pus flakes. Streptococcus mucosus 
produces a mucous pus of slight fluidity, and the influenza bacillus leads 
to hemorrhagic abscesses. Fetid abscess contents point to grave in- 
fections (scarlet fever, measles, diphtheria) or to chronic general affec- 
tions (tuberculosis). Fetid pus is also found in mastoiditis occurring in 



Fig. 76. 




Fig. 77. 




Purulent mastoiditis with multiple fistula formation (a, b, c) and fistulous perforation into the sulcus 

sigmoideus (d). 



the course of chronic suppuration of the middle ear. Gaseous abscesses 
of the mastoid process are rare, being found only in cases where the 
abscess has resulted from chronic suppuration of the middle ear. 

With a mastoid abscess enclosed on all sides, the pus is under con- 
siderable pressure, and immediately exudes upon resection, sometimes 
under pulsation. This would indicate that the mastoid abscess has 
advanced to the dura or that an extradural abscess has already de- 
veloped. Where the abscess communicates with the antrum there can 
be no question of any particular pressure within the abscess. 

Etiology. — There are primary and secondary purulent mastoiditis to 
be differentiated. Primary mastoiditis is very rare. It occurs from the 
entrance of pyogenic factors into the mastoid itself, where they cause in- 
flammation, while the other middle-ear spaces either remain uninvolved 
or merely show catarrhal changes of the mucosa. Such a localized effect 
of the infectious germ is favored by preceding traumatic injury to the 



AFFECTIONS OF THE MIDDLE EAR 169 

mastoid. There are greater chances for it to occur where there has been a 
previous inflammation than where the mastoid has always been healthy. 

Typical secondary mastoiditis is of much more frequent occurrence, 
and is due to the spreading of a middle-ear suppuration which had so far 
been confined to the tympanic cavity and antrum, to the mastoid process. 
The involvement of the mastoid occurs either after the type of continuous 
extension (chiefly in the mastoid air spaces) or after the type of metastatic 
suppuration (chiefly in the diploic mastoid) . In the former case the mas- 
toid abscess is in communication with the rest of the middle-ear spaces 
from the beginning; in metastatic abscess formation the abscess may at 
first be closed on all sides, and a communication with the other middle- 
ear spaces is only created by perforation of the abscess into the antrum. 
As a matter of course, there are many transition forms, which is intelli- 
gible from the fact that the mastoid is only rarely pneumatic or diploic 
throughout, and that in the majority of cases there is a so-called mixed 
mastoid, containing diploic as well as pneumatic regions. 

Mastoiditis and middle-ear suppuration occur at widely different 
periods. Anatomical examination of cases of acute otitis media where 
the suppuration has existed only a few days shows, to the surprise of 
the examiner, that the mastoid cells nearly always contain pus. It is 
evident that in a large number of cases pus enters the mastoid from the 
antrum in certain positions of the head or body, or through other phys- 
ical causes, without giving rise to any material co-inflammation of the 
mastoid. In most cases these changes will rapidly return to normal, so 
that at the end of the first week of the middle-ear suppuration the mas- 
toid region is again normal and free from pain. 

The typical acute purulent mastoiditis sets in during the three or 
four weeks of acute middle-ear suppuration after more or less prodromal 
signs, at a time when the secretion from the external auditory duct 
usually still persists. 

Occasionally the symptoms of mastoiditis will not occur until the 
close of the perforation and arrested secretion from the external duct, 
but the impairment of hearing acuity will indicate that the tympanic 
cavity is by no means normal yet. 

Acute mastoiditis occurring in the course of chronic suppuration 
of the middle ear is exclusively due to direct spreading of the pus to the 
mastoid process. The ultimate cause is usually acute suppuration of a 
cholesteatoma, or acute retention owing to stenosis of the auditory duct 
or polyp formation. In many of these cases the endocranium will be 
involved, either simultaneously or at a later period. 

Symptoms. — According to localization there are to be distinguished : 
(1) symptoms of the mastoid itself, (2) other ear symptoms, (3) cerebral 
symptoms, (4) general symptoms. 



170 THE DISEASES OF CHILDREN 

1. Mastoid Symptoms. — In the first place there is swelling of the 
soft covers of the mastoid. Thickening of the lateral periosteum can 
be established by comparison with the normal side. It can be distinctly 
felt that on the affected side there is between the palpating finger and 
the osseous surface a thicker soft layer than on the healthy side. The 
physician takes up a position behind the patient and palpates bilaterally 
with the first and second fingers between mastoid and concha, trying to 
advance in the direction of the crista temporalis inferior. In advanced 
cases the skin over the mastoid is tense, glistening, and hypersemic. 
There is also spontaneous and pressure pain of the mastoid, especially 
at the apex. The inflammatory (collateral) oedema of the soft mastoid 
covers leads to cleft-like constriction of the external auditory duct. 
The anterior wall of the mastoid and antrum forms at the same time 
the posterosuperior wall of the osseous external duct. Inflammation of 
the interior of the mastoid causes swelling of the periosteal investment 
of the auditory duct at this spot and descent of the posterosuperior 
osseous wall of the auditory duct (Fig. 75). At the same time the antero- 
superior wall of the membranous part is passively stretched, so that the 
transverse section of the duct has the form of a fissure running in an 
anterosuperior to a postero-inferior direction (Fig. 74). The charac- 
teristic point is that in advanced cases the swelling increases toward 
the tympanic membrane and that the latter cannot be inspected owing 
to the cleft-like constriction of the auditory duct, the deep part of the 
latter being impassable for the speculum. 

The cedematous swelling of the soft mastoid covers leads to the 
pathognomonic change of position of the concha. The concha is de- 
flected laterally and is at a lower level than on the healthy side, and there 
is antero-inferior torsion (Figs. 78, 79). This position anomaly is par- 
ticularly striking in the posterior aspect (Fig. 79). 

2. The Other Ear Symptoms. — Special signs may be absent. Re- 
duced hearing distance (33^-7 feet C), which persists for weeks, points 
to considerable accumulation of secretion and a further dissemination 
of the inflammatory changes in the middle-ear spaces. In other cases 
a suspicious sign, setting in shortly after the secretion has begun, con- 
sists in the great quantitative variation of the evacuated secretion. On 
some days or at certain hours it is above normal, while at other times it 
is very slight or absent for a shorter or longer period, although the other 
inflammatory manifestations (fever, pain, impaired hearing) continue. 

In a case of acute suppuration of the middle ear which runs a normal 
course, the pus secretion presents a characteristic picture: the tympanic 
membrane having been perforated, the secretion rapidly increases dur- 
ing the first twenty-four hours, remains at the same level during the 
next few days, and, aside from variations which are not accompanied 



AFFECTIONS OF THE MIDDLE EAR 



171 



by pain or fever, decreases in quantity with spontaneous improvement 
of the hearing acuity. As the quantity of the secretion decreases, the 
pus is more and more infiltrated with mucus, and as the inflammatory 
manifestations abate, it becomes stringy and inspissated. 

The acute diminution of the secretion is often observed at just the 
time that the local mastoid signs intensify. In the presence of pus 
retained in the tympanic cavity, there are violent, throbbing ear pains, 
like those occurring in the beginning of otitis media. 

In other cases again profuse otorrhcea, which persists for weeks, 
and obstinate earache point to the involvement of the mastoid process. 



Fig. 78. 



Fig. 79. 




Pathognomonic position of the concha in acute purulent mastoiditis. Boy 14 years old. 



3. The cerebral symptoms consist in diffuse headache, which is usually 
localized toward the affected side. Sometimes there are vomiting, vertigo, 
or convulsions in the initial stage. 

4. Among the general symptoms elevation of temperature should 
be mentioned first. It is principally present in the first stage of mas- 
toiditis, later in circum vallate mastoid abscesses. Febrile ascents up to 
104° F. and more are observed in children in the beginning of mastoiditis. 
Variations of temperature are frequent, and depend upon the free or 
impeded escape of the secretion. Fever may be entirely absent if the 



172 THE DISEASES OF CHILDREN 

abscess is perforated or communicates from the first with the antrum 
and the tympanic cavity. Immediate fall of the temperature to normal 
or subnormal, followed by renewed access of fever, cannot be explained 
by simple mastoiditis, but rather points to intracranial involvement and, 
above all, to an affection of the venous sinuses. The frequency of pulse 
and respiration is increased in proportion to the fever. The general 
impression of the patient chiefly depends upon his subjective complaints. 
If there are considerable regional pain, general physical unrest, es- 
pecially at night, lassitude, anorexia, bad complexion, the patient gives 
the impression of being a very sick man. On the other hand, cases in 
which there are no subjective pathological manifestations whatever are 
by no means rare, even in the presence of a large mastoid abscess. 

Unusual and general symptoms give rise to the suspicion that mastoid- 
itis is notthe only affection caused by the underlyinginfection. Inthepres- 
ence of chills, delirium, icterus, localized headache, impaired motility of the 
head and vertebral column, we shall not be content with the diagnosis of 
"inflammation of the mastoid process," but it is our duty to search for 
another accompanying affection, — above all, an endocranial involvement. 

Diagnosis. — Taking all the above symptoms into consideration, 
there can be no difficulty in arriving at a diagnosis of acute mastoiditis. 
Inspection of the patient from the base of the skull (Fig. 79) is of im- 
portance. The abnormal position of the ear will then be at once apparent 
in cases in which it may escape the eye of the observer in the anterior 
aspect. The examination has to be repeated, if necessary. It stands to 
reason that the symptoms are not alike in degree and intensity in all 
cases, and it may require very careful examination and considerable 
experience to guard against overlooking an inflammation. If the mas- 
toid manifestations are slight, suppuration from the middle ear lasting 
for more than four weeks and continuously affecting the hearing ability 
points to an abscess of the mastoid process. In the absence of any other 
manifestations, the very descent of the posterosuperior wall of the 
osseous duct may lead to the correct diagnosis. 

In doubtful cases transillumination of the mastoid may render good 
service. Two small cold electric lights of special construction are in- 
troduced into the two auditory ducts. The normal mastoid allows a 
fair quantity of light to shine through, the pneumatic mastoid appearing 
light red and the dipolic mastoid deep red. The posterior border of 
the diaphanous part usually coincides with the hair border in the normal 
individual, while in inflammatory affections of the mastoid the patho- 
logical side is much less permeable to light than the healthy one, and 
the shadow border will be a considerable distance in front of the hair 
border. Unimportant deviations in the diaphanic properties, however, 
do not constitute any point of diagnostic value. 



AFFECTIONS OF THE MIDDLE EAR 173 

The diagnosis of acute mastoiditis may also be aided by X-ray 
examination, although any mastoid changes thereby disclosed would 
be of no diagnostic value unless supported by clinical symptoms. 

The difference in temperature between the affected and the healthy 
mastoid regions is of diagnostic value, although important and easily 
recognizable differences will only be present after the other local symp- 
toms are fully developed. It requires considerable experience to recog- 
nize slight differences. 

Differential Diagnosis. — There are three affections to be differen- 
tiated: (1) otitis externa furunculosa; (2) erysipelas of the auricular 
region; (3) pediculosis capitis with lymphangitis of the scalp, as well as 
moist eczema and furunculosis of the scalp. 

Simple furunculosis of the auditory duct may cause far-reaching 
oedema of the auricular region, resulting in pasty swelling of the cover- 
ing of the soft mastoid parts, perhaps hypersemia of the skin, and in 
rare cases in fluctuation, the latter occurring particularly in deep ramified 
abscesses and tuberculous inflammation of the external ear. 

In these cases the differential diagnosis presents no difficulties. In 
the first place, there is either slight or no painfulness, spontaneous or 
on pressure. Since furuncles of this kind are usually situated at the 
base of the external meatus, the base of the concha is raised by the 
oedema, causing the entire concha to assume a higher position than 
normal (Figs. 63a and 636). Nor is the cedema confined to the mastoid 
region, spreading as it does to the parotid region and in typical cases 
to the lower eyelid. Upon examination of the affected external duct no 
changes will be found in that region except those of positive furuncu- 
losis (circumscribed swelling, painful pressure point at the tragus). 

The Assure-like constriction in acute mastoiditis is particularly 
conspicuous in the region of the osseous duct, while in inflammation of 
the external auditory duct the constriction is confined to the membranous 
part of the duct. If in otitis externa a small ear-speculum has passed 
the constriction, it is very easy to establish with the aid of the otoscope 
the fact that the osseous duct is normal and that the tympanic mem- 
brane and the hearing acuity have undergone no change, provided the 
external duct is maintained in a permeable condition by means of the 
funnel. On the other hand, the patient will experience pain in masti- 
cation, which is not the case in true mastoiditis (except in inflammatory 
ankylosis due to perforation of the abscess toward the maxillary articu- 
lation). The temperature is either normal or but slightly elevated in 
otitis externa. 

The differential diagnosis becomes more complex if there is also 
otitis media in addition to otitis externa, and inspection of the tympanic 
membrane is prevented by granulations or accumulated crusts, or if 



174 THE DISEASES OF CHILDREN 

the hearing acuity is reduced owing to maceration of the epidermal 
layer of the tympanic membrane. In these cases, however, the decision 
will be rendered possible either by repeated careful examination and 
observation for one or two days, or in cases of ulceration by the opera- 
tive findings. 

Cranial erysipelas, spreading to the auricular and mastoid regions, 
may give rise to manifestations which resemble those of acute mas- 
toiditis. The history (not a preceding affection of the ear), together 
with the normal auricular findings, will protect against error, while a 
precise examination at daylight will disclose the characteristic demarca- 
tion of the dermatic swelling. 

Pediculosis capitis, notably of the vertex and occiput, may be 
accompanied by inflammation of the lymph-vessels, with swelling of 
the skin and painful swelling of the mastoid glands. Examination of 
the auditory duct, the exact history, and, above all, the bilateral 
involvement of the mastoid region in pediculosis capitis will render a 
correct diagnosis possible. 

Treatment. — Conservative treatment of acute mastoiditis is chiefly 
supported by appropriate treatment of the middle-ear inflammation, 
preventing stagnation of the secretion and avoiding unnecessary irri- 
tation. Should signs develop pointing to involvement of the mastoid 
process, absolute rest in bed is advisable. Cold compresses (ice-bag, 
Leiter's apparatus) usually render good service in the beginning of the 
affection, but at later stages patients usually prefer warm applications 
(thermophore, cataplasms). If compresses prepared with acetic alu- 
mina or 1-2 per cent, alsol, or alcohol, are used, the ice-bag or thermo- 
phore is applied laterally over the compress, with patient in the dorsal 
decubitus. Painting with iodine or applying silver ointment (ung. col- 
loidale) has furnished no convincing proof of usefulness. Bier's hyper- 
emia deserves a trial with patients who can be constantly observed in a 
hospital. I have never seen any very remarkable results from this 
proceeding, but it appears that in appropriate cases involution of the 
inflammatory mastoid manifestations is favorably influenced. But a 
curative effect cannot be expected from Bier's hyperemia in cases 
where suppurative transformation of the tissue and abscess formation 
in the mastoid have already taken place. On the contrary, cases which 
had been subjected to this procedure and which later had to be oper- 
ated upon usually gave the impression as if hypersemic stasis were 
responsible for the rapid spreading of the pus to all the cavities of the 
mastoid and even for the perforation of the abscess. 

Resection of the mastoid is indicated if there are no distinct signs 
of an abatement of the mastoid symptoms after all conservative meas- 
ures have been exhausted. 



AFFECTIONS OF THE MIDDLE EAR 175 

Indications. — The indications are perfectly clear in cases which 
have been observed from the beginning of the middle-ear inflammation 
and where the development of mastoiditis could be plainly followed. 
Operative interference is a matter of necessity where, in spite of appro- 
priate treatment, the development of mastoiditis could not be prevented. 

The decision is more difficult in cases of acute mastoiditis which 
could only be observed after prolonged existence of otitis media which 
has not had the benefit of competent treatment or of any treatment at 
all. In the absence of severe symptoms, such as great pain, high tem- 
perature, etc., a waiting attitude under strict supervision may be justi- 
fied for a time. Every experienced specialist is aware of the fact that 
cases of this kind, presenting the manifestations of mastoiditis, may 
undergo involution with rest in bed and local treatment. There may be 
nothing but inflammatory irritation which disappears as soon as the 
patient is given the opportunity of rest and care, such involution pro- 
ceeding more rapidly in some cases than in others. 

Cases of entirely circumvallate mastoid abscesses may suddenly 
come to a favorable termination, as I have repeatedly had occasion to 
observe. Thus, a girl 14 years old, suffering from suppurative middle- 
ear inflammation, developed manifestations of acute mastoiditis in the 
third week. Conservative treatment gave no improvement, but, at 
the urgent request of the parents and in the absence of threatening 
symptoms, this was continued for three weeks. As there was no im- 
provement, pains and swelling persisting, operation was finally decided 
upon for the following morning. During the night the abscess perforated 
into the antrum and thence outward through the opening of the tym- 
panic membrane. Eight days later the patient was completely restored. 

The value of the separate symptoms of mastoiditis, so far as indica- 
tions for operation are concerned, stands in relation to the duration of the 
middle-ear suppuration. It is not a rare occurrence that mastoid symp- 
toms (pain on pressure, slight swelling of the soft covers) occur in the be- 
ginning of otitis media as partial manifestations of a suppurative inflam- 
mation in the tympanic cavity and antrum, which would indicate that the 
mastoid manifestations represent a distinct effect of the middle-ear in- 
flammation. As a rule, these symptoms disappear within a few days 
after the pus has been properly evacuated by paracentesis. 

In the course of acute infantile infections, mastoid symptoms in 
the beginning of acute attic suppuration or in otitis media are of especial 
importance, as unsuccessful paracentesis and continuation of the mastoid 
manifestations would indicate involvement of the mastoid process. As 
a rule, the symptoms are not fully developed until the fourth week. 

In prolonged cases, on the other hand, the symptoms to go by are 
often very few. Thus, important local mastoid signs may be absent 



176 THE DISEASES OF CHILDREN 

as soon as the abscess has perforated toward the dura. In these cases 
the indication for operation is continued poor hearing and persistent 
dropping of the posterosuperior wall of the auditory duct. In cases, 
however, where the middle-ear inflammation has been cured, the indi- 
cation for operation is given by persistent pain in the mastoid region, 
with headache, and continuous though slight elevation of temperature. 
The importance of bacteriological findings is not to be underrated, 
but it need not be emphasized that the microscopically and culturally 
demonstrable micro-organisms must emanate from a secretion taken 
under sterile precautions from the tympanic cavity in the beginning 
of the inflammation (on the occasion of paracentesis). On the other 
hand, no reliable result can be expected from the pathological examina- 
tion of pus spontaneously exuding through the external meatus. Should 
the presence of streptococcus mucosus, S. pyogenes, or bacillus pyo- 
cyaneus be demonstrated, early operation is advisable. 

The age of the patient likewise is a point to be considered. Up to 
8 years the mastoid abscess is nearly always in communication with 
the antrum. The spontaneous evacuation into the tympanic cavity in 
infancy is, therefore, a far more likely occurrence than in older children 
or adults. Besides, the lateral antrum wall is thin, in rhachitic children 
often cartilaginous in parts, so that a spontaneous perforation of the 
abscess outwardly under formation of a subperiosteal abscess is to be 
expected early, and the danger of the mastoid abscess perforating toward 
the dura under a waiting attitude is comparatively slight. 

In older, anaemic children who have been weakened by other illness, 
the formation of extensive mastoid abscesses often presents but slight 
local symptoms. The periosteal swelling of the lateral wall may be 
slight or entirely, absent in the presence of a thick corticalis. 

Grave constitutional or advanced organic affections contraindicate 
resection of the mastoid in uncomplicated suppurative mastoiditis. In 
cases of this description operation is desisted from (1) on account of 
dangerous postoperative possibilities and (2) owing to the probability 
of unfavorable healing, accompanied, as it usually is, by profuse secre- 
tion, leading to rapid marasmus. In diabetes there is besides the danger 
of coma diabeticum immediately following operation. 

In advanced tuberculosis, in general debility, or in bilateral in- 
volvement in bottle-fed infants, operation should only be resorted to if 
there is impending danger to life by the affection spreading from the 
mastoid to the interior of the cranial cavity. 

Method of Operation. — (1) Simple Resection of the Mastoid 
(Mastoidotomy). — The planum mastoideum is exposed and the cor- 
ticalis removed with the chisel and Luer's bone-forceps, corresponding 
to the lateral surface of the mastoid process. Chisel work commences 



AFFECTIONS OF THE MIDDLE EAR 



177 



in the mastoid triangle (Fig. 80). The abscess having been evacuated 
and the softened osseous parts removed, the edges of the corticalis are 
resected far enough to let the traumatic cavity in the bone form an 
obtuse angle with the corticalis. Should the mastoid apex seem to be 
involved, it is advisable to detach the outer part of the tendon of the 
sternocleidomastoid and to remove the apex with Luer's bone-forceps. 
An iodoform, isoform, or simply sterile wick is inserted into the wound. 
In this way the traumatic cavity is loosely packed and the skin closed 



Fig. 80. 



Tsm 




Fig. 81. 



Cti 




a b Tsme 

Fig. 80. — The mastoid triangle (a, blue) results from the linear connection of the torus supramastoideus 
(Tsm), the tuberculum suprameatum (Tsme), and the mastoid apex. The antrum triangle (6, red) results from 
the linear connection of the torus supramastoideus and the tuberculum suprameatum with the lowest point 
of the porus acusticus externus. (§ natural size.) Cti, crista temporalis inferior. 

Fig. 81. — Right ear. A antrum mastoideum; Cti, crista temporalis inferior. (§ natural size.) 

by sutures or Michel's clamps up to the drainage angle, carefully avoid- 
ing the periosteum. A sterile gauze strip is inserted into the previously 
cleansed auditory canal. 

(2) Opening the Antrum; Antrotomy. — The operation is com- 
menced in the same way as simple resection of the mastoid. The bone 
is chiselled off in an anterosuperior direction, closely following the 
direction of the upper auditory wall (Fig. 81). Small pneumatic cells 
indicate the immediate proximity of the antrum, as does the escape of 
air bubbles. Should the abscess cavity extend to the middle wall of 
the mastoid, it is advisable to resect the bone edges and the external 
margin of the osseous posterior wall of the auditory duct. 

The wound is attended to in the same way as after mastoidotomy. 
Scraping the resected antrum may easily lead to luxation of the incus 
and should therefore be avoided. 

Should the healing process take a regular course without reactions, 
the first change of bandages should take place on the sixth day, the 

VI— 12 



178 THE DISEASES OF CHILDREN 

wicks being shortened at the same time. During the second week the 
bandages are changed daily, with gradual shortening of the wicks, so 
that with the third or fourth change all the wicks are removed. Gauze 
strips are now inserted into the auditory meatus and tympanic cavity. 
After-treatment of the resected antrum need not be troubled about; 
repeated sounding, cauterization, or irrigation will interfere with the 
healing process and may give rise to a permanent antrum fistula. As a 
rule, healing takes place by the traumatic cavity filling up with granu- 
lation tissue, which finally changes into connective tissue. In young, 
vigorous individuals there will be new-formation of the cortex from 
the periosteum, if preserved. Regeneration of the osseous trabecula 
within the mastoid itself occurs but very rarely. It is inadvisable to 
attempt obliteration of the mastoid connective tissue and new-formation 
of the cortex in debilitated individuals or where the traumatic cavity 
is unusually extensive or deep. The skin should rather be pulled into 
the traumatic cavity by simple traction sutures, with a view to effect- 
ing direct union of the epidermal layer with the osseous wall by tam- 
ponade under moderate pressure, although the cosmetic effect will be 
impaired by a deep scar in the mastoid region. But this is compensated 
for by the solid healing, while in primary suture down to the lower 
traumatic angle the conditions referred to — debilitation and deep trau- 
matic cavity — may easily cause the healing to take place at the level of 
the skin, with a chronic abscess remaining below, which may perforate 
many months later and require scraping or renewed operation. It is 
for this very reason that "healing under the blood scab," as advocated 
by some authors, with complete primary closure of the skin wound, is 
objectionable, destroying as it does the possibility of controlling the 
healing process, and possibly leading in- apparently healed cases to very 
unpleasant surprises, suppuration of the blood scabs weeks afterward, 
and formation of new abscesses. 

The average time required for healing after simple resection of the 
mastoid process is 3-4 weeks, after antrotomy 5^-7 weeks. Should the 
healing process take a dragging course, it may be stimulated by illumi- 
nation of the traumatic cavity (sunlight, Auer lamp, cold electric bulbs 
introduced into the cavity) and scarlet red ointment. Silver nitrate 
ointment is not recommended, as silver nitrate even considerably diluted 
will almost without exception cause suppurative relapses if any part of 
it reaches the tympanic cavity through the open antrum. However, 
when the traumatic cavity is entirely obliterated and the antrum com- 
pletely closed, the final closure of the skin wound can be accelerated by 
the nitrate stick. The healing process will also be aided by nutrition, 
avoidance of physical efforts, and fresh air. Sojourn at the sea-coast 
and sea-baths often have a remarkably favorable effect. 



AFFECTIONS OF THE MIDDLE EAR 179 

Uncomplicated cases of mastoiditis in which the middle-ear sup- 
puration has not been of long duration will heal with complete anatomi- 
cal and physiological restoration of the middle ear: tympanic cavity, 
membrane, and hearing distance will become normal again. If, however, 
the middle-ear suppuration should have lasted for several months, there 
may be cicatrization of the tympanic membrane and development of 
connective-tissue layers in the tympanic cavity as well as permanent 
reduction of the hearing acuity. 

Simple resection of the mastoid will not answer the purpose unless 
the bone toward the antrum is absolutely intact. Should the bone be 
affected, or in doubtful cases, antrotomy should be performed. 

Wilde's incision in acute mastoiditis has been rightly abandoned. 
It may perhaps be in place to relieve any considerable tension of the 
covers of the soft parts (in subperiosteal abscess) where local conditions 
will not permit of immediate bone operation, but then it is only a tem- 
porary help preparatory to the bone operation. 

Acute infantile mastoiditis is characterized by early spontaneous 
perforation outward and formation of a subperiosteal abscess. The 
majority of the cases are recruited from under-nourished, weak infants 
of from patients suffering from acute otitis running along with scarlet 
fever or measles. 

The youngest infant I have observed with purulent mastoiditis 
and subperiosteal abscess was three months old. In one infant seven 
months old, bilateral mastoiditis with subperiosteal abscess developed 
in the course of one week. 

Suppurative infantile mastoiditis is quite often caused by tubercu- 
lous middle-ear suppuration, the former developing in the shape of tuber- 
culosa osteoperiostitis, whereas purulent osteoperiostitis of the temporal 
squama and the superior wall of the auditory canal occurs less often. 
Owing to secondary pneumo- or streptococcus infection, extensive sub- 
periosteal abscesses may here be formed which may finally reach the 
occiput and base of the skull posteriorly and the lateral canthus of the 
eye anteriorly. 

IX. CHRONIC MIDDLE-EAR SUPPURATION 
1. SIMPLE CHRONIC MIDDLE-EAR SUPPURATION 
The simple forms of chronic middle-ear suppuration are those in 
which the pathological process has been confined to the mucosa of the 
middle ear in a prolonged course of the affection without spreading to 
the bone. 

In chronic suppuration of the mucosa the latter has become swollen 
and softened, leading to chronic ulceration and granulation, possibly 
to the development of granulating polyps. On the other hand, the 



180 THE DISEASES OF CHILDREN 

occurrence of myxomatous polyps enclosed in an epidermal layer, as 
well as the presence of cholesteatoma, is evidence of the inflammation 
having spread from the mucous membrane to the osseous parts of the 
middle ear. 

Etiology.— Simple chronic middle-ear suppuration develops from 
the acute form if circumstances prevail which cause the inflamed, pur- 
ulent state to continue, preventing the reduction of the inflammation 
in the acute or subacute stages. These causes may lie in the middle 
ear itself : perforation in the acute stage of otorrhoea may be prematurely 
constricted or occluded by granulation; or the acute middle-ear sup- 
puration may have occurred after the pathological septa had been 
formed in the tympanic cavity from previous catarrhal affections. Free 
evacuation of pus in the acute stage of purulent inflammation is impos- 
sible in either case, the consequence being that the mucosa undergoes 
extensive ulceration owing to decomposition of retained pus. These 
ulcerations behave differently according to which part of the middle 
ear they occupy. Thus, it may happen that the pathological process in 
one part of the tympanic mucosa may heal while the ulcerations spread 
to a hitherto healthy portion. 

In other cases the chronic suppuration persists owing to catarrhal 
changes in the nasopharyngeal space. Insignificant causes, such as a 
simple rhinitis, may be sufficient to develop an acute tubal catarrh on 
the basis of chronic catarrhal changes, rekindling the old middle-ear 
suppuration on each occasion. The consequence is that the slight 
quantity of pus still present becomes profuse (pulsating pus), or sup- 
puration may start afresh after the secretion had been temporarily 
arrested. The latter kind of relapse is .of frequent occurrence in children. 

There is also danger of chronic middle-ear suppuration when a 
weakly, anaemic, or tuberculous patient, with little power of resistance, 
contracts acute inflammation of the middle ear. In acute infantile 
cases the danger of chronic development is. therefore especially great, 
as two unfavorable factors cooperate: (1) an acute inflammation run- 
ning a severe, violent course, with rapid destruction of the soft parts, 
and (2) impaired power of resistance owing to a previous infectious 
disease (scarlet fever, measles, etc.). 

Tuberculous middle-ear suppuration shows from its very beginning 
a tendency to a chronic course, and the same danger prevails in the 
epitympanic forms. This perforation is limited in size by the smallness 
of Shrapnell's membrane (Fig. 82, 5), and the upper tympanic cavity 
is difficult to drain, due to the position of the auditory ossicles and the 
numerous folds of the mucosa. These forms, however, are but rarely 
confined to the mucosa, and usually spread to the osseous parts of the 
epitympanum. 



AFFECTIONS OF THE MIDDLE EAR 



181 



Symptoms. — The pathological picture throughout presents the 
symptoms of chronic otorrhcea. The consistency of the secretion varies : 
in simultaneous catarrhal changes of the nose and nasopharyngeal space 
it is often mucous; in the presence of granulations and polypi (Figs. 
82, 83, and Plate VIII) it is often hemorrhagic. The pus is usually 
fetid in neglected cases, never in those properly treated. The condition 
of the tympanic membrane is at once characterized by the presence 
of the perforation, which embraces several smaller or larger parts of the 
membrane and presents the most variegated configurations (Figs. 82, 83, 
Plate VIII). The manubrium is intact in many cases, and the margin 
of the perforation does not reach up to the insertion of the tympanic 
membrane. In other cases the larger part of the membrane and manu- 



Fig. 82. 







TsCh 






Tympanic membranes in chronic middle-ear suppuration. Right side 1-5; left side 6 and 7. 1. Kidney- 
shaped perforation. 2. Heart-shaped perforation with preserved manubrium. 3. Oval perforation the size of a 
hemp-seed; antero-inferior aspect; central lime deposits fused with the manubrium. 4. Large roundish defect 
of the tympanic cavity; the background of the perforation is furnished by the promontory. 5. Perforation of 
Shrapnell's membrane; epitympanic chronic suppuration. 6. Marginal perforation of the posterosuperior 
quadrant. The incus-stapes connection, the upper part of the promontory and of the fenestra cochleae are visible 
in the perforation gap. Chronic suppuration of the antrum. 7. Marginal kidney-shaped perforation of the 
two posterior quadrants. The following parts are visible in the perforation gap: chorda tympani (Ch), incus- 
stapes connection (Is), fenestra cochlear (Fc), and the promontory (P). 

brium is destroyed. Lime deposits of varying extent can often be ob- 
served. Again, the lateral surface of the tympanic membrane may be 
ulcerated (chronic myringitis ulcerosa), or the epidermal layer of the 
remaining part of the membrane is intact while the remnant itself is of a 
dull or grayish red. In chronic middle-ear suppuration with temporarily 
arrested secretion there may be profuse ligament formation in the middle- 
ear spaces in intermittent periods of healing (Plate VIII). These liga- 
ments are apt to lead to synechia of the remnant of the membrane or 
manubrium with the wall of the tympanic cavity, to obliteration of the 
corners of the fenestra, or, finally, to obliteration of the tympanic cavity 
itself (chronic adhesive process following chronic midde-ear suppuration). 



182 



THE DISEASES OF CHILDREN 



The mucous membrane of the tympanic cavity is hypersemic, swollen, 
covered with pus, and often ulcerative. Granulations or polypi from hemp- 
seed to pea size are likewise encountered in the hypo- and epitympanum 
(Figs. 82, 83, and Plate VIII). The mastoid region is normal. 

The auditory canal is intact in simple chronic middle-ear suppura- 
tion; the mucosa of the osseous duct is neither lividly discolored nor 
ulcerative. The duct itself as well as the mastoid process is unchanged, 
and the chain of auricular ossicles is preserved. Pus can either be freely 
evacuated or whatever retention there may be can be easily overcome. 
There is no cholesteatoma. 

The subjective symptoms consist in a feeling of fulness in the ear 
or head and in subjective noises. There may be pain in the presence of 
extensive ulceration or pus retention. The funnel test shows all the 
signs of an obstacle to conduction, with medium or high-grade reduction 
of the hearing acuity. In degeneration of Corti's organ there are also 



Fig. 83. 







12 3 4 5 

Tympanic membranes of the right ears in chronic middle-ear suppuration after acute infections. 1-3. Chronic 
middle-ear suppuration after scarlet fever. 4-5. Chronic middle-ear suppuration after measles. 1. Kidney- 
shaped perforation of both posterior quadrants. At the base of the perforation the long pillar of the incus, the 
fenestra cochleae and the promontory are visible. 2. Heart-shaped perforation with handle of malleus intact. 
The junction of the stapes and incus, the promontory and the fenestra cochlea? are visible through the perfora- 
tion. 3. Total destruction of the pars tensa of the tympanic membrane. The short process of the malleus and 
the membrana flaccida are intact, the incus is destroyed. Through the perforation the head of the stapes and 
the fenestra are visible. The promontory, tympanic opening of the tube and the ridge of the hypotympanum 
are to be seen. 4. Complete destruction of the tympanic membrane with absence of incus and stapes. The pos- 
terior half of the field of vision is filled with granulation tissue growing from the hypotympanum. The re- 
mainder of the field is swollen and congested. 5. Heart-shaped defect in the membrane with malleus and both 
anterior quadrants intact. The incus is destroyed. The stapes, fenestra cochleae, chorda tympani and the 
promontory are visible through the perforation. 

the clinical signs of an affected internal ear, consisting in considerable 
reduction of the hearing acuity, lowering of the upper sound limit, 
shortened perception of high sounds, and shortened bone-conduction. 

Chronic middle-ear suppuration is often accompanied by degenera- 
tion of Corti's organ at the base of the cochlea, which, according to 
anatomical findings, consists in connective-tissue proliferations emanat- 
ing from the base of the cochlea and leading, as a secondary manifesta- 
tion, to degeneration of Corti's organ and the cochlear nerve of the ves- 
tibular portion. This degenerative atrophy of Corti's organ may grad- 
ually spread to the other parts of the cochlea. 

Diagnosis of Simple Chronic Middle-ear Suppuration. — The founda- 
tion of the diagnosis is supplied by the otoscopic findings (Plate VIII 
and Figs. 82, 83) and the history. In order to assume the presence of 



AFFECTIONS OF THE MIDDLE EAR 183 

uncomplicated chronic suppuration of the mucous membrane, as against 
the surgical forms, the entire auditory canal must be demonstrably 
intact. Exclusion of cholesteatoma requires microscopical examination 
of the pus evacuated from the middle-ear spaces, always observing the 
precautions described on p. 199. Several days or weeks of observation 
may be required to determine whether the suppuration has been con- 
fined to the mucous membrane or whether it has attacked the bone. 
Pus retention is usually indicated by annoying head pressure, headache, 
earache, and, possibly, elevation of temperature. There is a purulent 
secretion in the middle-ear spaces, rapidly accumulating behind the 
drain, sometimes within a few minutes after the most careful cleansing, 
which, however, can be aspirated with Siegle's funnel immediately after 
the examination. A healthy condition of the bone is indicated by the 
fact that the fetid character of the suppuration completely disappears 
within a few days under antiseptic treatment energetically directed to 
drainage and systematic cleansing of the middle-ear spaces. 

Treatment. — Conservative treatment is indicated in nearly all 
cases of simple chronic middle-ear suppuration. Pathological tissue 
proliferation of the middle ear, granulations, or polypi, if present should 
first be removed surgically. Otherwise conservative treatment, as out- 
lined below, should be instituted at once. Removal of the polypi and 
auricular ossicles is merely a preliminary procedure to render conserva- 
tive treatment effective by making the occluded middle-ear spaces 
accessible. 

(a) Removal of Granulations and Poly-pi. — Local anaesthesia, as 
described on p. 97, is employed in the removal of polypi, either by cauter- 
ization or the knife. If the latter is used, cauterization of the base of 
the polypus is done one or two days after removal. By far the best 
cauterizing agent for the middle ear, by reason of its positive effect, is 
crystallized chromic acid (chromic acid pearl) which has been united 
with the tip of a probe by melting over a flame. None but flat granula- 
tions which are clearly visible in the otoscopic picture are suitable for 
cauterization. Large granulations or polypi are best removed with 
small forceps or snares. There are cutting snares and pressure snares, 
the former cutting through the polypus at the place of application, 
while constricting loops firmly encircle the polypus and usually detach 
it at the base when traction is made. It is, therefore, easier with the 
latter instrument to remove a polypus in one sitting than with the 
cutting snares; but there is danger of traumatic injury of the base of 
the polyp from sudden tearing off of the growth. For this reason, con- 
striction snares should not be used for polypi which originate in the 
superior cavity, as the previously affected osseous roof of the tympanic 
cavity may be easily injured and develop a suppurative meningitis. 



184 THE DISEASES OF CHILDREN 

No irrigation of the middle ear should be done immediately after re- 
moval of a polypus. The auditory canal and the middle ear are packed 
as thoroughly as possible with iodoform gauze, and a bandage is applied. 

The gauze strips are removed in 24 hours; hemorrhage, if any, is 
arrested with cotton tips saturated with adrenalin. The stump of the 
polyp, which must be distinctly visible in the otoscope, is cauterized 
with chromic acid on the same or the following day. 

(b) The Conservative Treatment of Chronic Middle-ear Suppuration. — 
The most important object of the treatment consists in removal 
of the secretion from the middle-ear spaces and drying up the patho- 
logically changed secreting mucous membrane. The secretion may be 
removed either by irrigation or dry cotton tips. The secretion collected 
in the tube is conveyed to the middle ear by Politzer's air insufflation 
and removed. 

The irrigation is effected either with sterilized water or with medi- 
cated fluids, such as hydrogen peroxide (1-2 tablespoonfuls of a 6 per 
cent, solution to 3^ litre of water) ; permanganate of potash, up to a light 
violet color; lysol or lysoform; formalin (5 drops of a concentrated 
solution — 42 per cent. — to 3^ litre of water) argyrol (1 :1000); alsol 
(1 teaspoonful to H _ l litre of water); sublamine (1 : 1000). 

The middle ear having been cleansed, antiseptic or astringent 
medicaments are applied, such as instillations of hydrogen peroxide, 
perhydrol (Merck) in 3-6 per cent, solution, or, if the mucosa is swollen 
and granulated, alcohol heated to 104° F. Alcohol is used owing to its 
hygroscopic properties in withdrawing water from the tissues and caus- 
ing hyperplastic mucosae to shrink. As alcohol usually causes a burning 
sensation, it should be first applied diluted, gradually using stronger 
solutions. Additions of 1-2 per cent, boric or salicylic acid are also useful. 
Alcohol, however, should be discontinued if it causes intense hyperemia 
or swelling of the affected mucosa. 

Introduction of Peru balsam or concentrated aqueous picric acid 
solutions sometimes exerts an excellent effect. E. Urbantschitsch rec- 
ommends thigenol (a composition of sodium and sulpho-oleic acid), owing 
to its anaemic, resorptive, and desiccating effect. 

R. Thigenol "Roche," 5.0; 
Spir. vin. dil., 30.0. 

or Thigenol "Roche," 5.0; 

Glycerin, 10.0; 
Perhydrol, 3.0; 
Spir. vin. rectif., 30.0. 

The following are astringent solutions : 

1. Acid, tannic. 0.5 : 25.0 glycerin, aq. dest. aa. 

2. Zinc. sulf. 0.05-0.2 : 20.0 aq. dest. 

3. Alum. crud. 0.1-0.2 : 20.0 aq. dest. 



AFFECTIONS OF THE MIDDLE EAR 185 

In cases of moderate secretion, medicated powders in small quanti- 
ties are blown upon the mucous membrane. This process should not be 
left to the patient or his attendants, since exaggerated quantities may 
cause a dry crust to form with consequent retention of the secretion. 
In using powders a change should be made from time to time, using 
alternately acid, boric, subtil, pulver., borodate, xeroform, airol, alma- 
tein, and iodol (particularly in tuberculosis). Politzer recommends the 
following in blennorrhceal secretions: Acid, boric, subtil, pulveris. 
5.0, 01. terebinth, gtt. v. 

Very good results are sometimes obtained in obstinate cases with 
instillations of 3-10 per cent, silver nitrate solutions or insertion of cor- 
responding cotton plugs, after the middle-ear mucosa has been carefully 
cleansed. Should there be great pain, the ear is immediately rinsed 
with tepid water. Instillation of a few drops of electrargol or insertion 
of cotton plugs saturated with this substance is sometimes very effective. 
Silver treatment is contraindicated in considerable granulation of the 
mucous membrane, in suppuration of the accessory spaces of the tym- 
panic cavity, and in acute exacerbations. 

In favorable cases there is often rapid diminution of the secretion 
in the course of a few days; cases where the secretion retains its fetid 
character in spite of careful cleansing and treatment are not suitable 
for conservative treatment. 

The decrease of the secretion can be observed by the patient or 
attendants by renewing the hydrophile or antiseptic gauze strips at 
regular intervals. 1 As improvement progresses, there will be no more 
secretion during the day, while the night strips are partly moistened in 
the morning; finally this moisture is likewise arrested. However, the 
dry condition of the strips will not justify the conclusion of the secretion 
being completely arrested: careful inspection may reveal a small crust 
or scab, the removal of which will start the secretion afresh. In 
these cases there is no need for inspecting the middle-ear spaces, as the 
strips will have a more or less objectionable odor in spite of their being 
perfectly dry. 

As soon as the secretion has definitely subsided, the mucous mem- 
brane usually returns to normal in a short time. The formation of 
epithelium is sometimes assisted by the insertion of a 3 per cent, epicarin 
or a 1 per cent, scarlet red ointment once or twice weekly. 

After the arrest of the secretion nothing but sterile gauze strips 
should be inserted, which are renewed both in the morning and evening 
for purposes of control. Cases which lend themselves to conservative 
treatment are cured in from three to six weeks. 



1 There are a large variety of antiseptic gauzes, such as xeroform and dermatol, isoform, 
airol, vioform, aristol, europhen, almatein, ectogen, loratin, and argentol. 



186 THE DISEASES OF CHILDREN 

(c) Closing of Persistent Perforations of the Tympanic Membrane. — 
In cases of long duration or great virulence of the pathogenic factors, 
defects of the tympanic membrane of variable extent may persist in 
spite of careful treatment. Ear specialists have endeavored for a long 
time to effect a closure of these defects, not only because they impair 
the hearing acuity, but also because of the risk of a new infection of 
the middle ear being caused by the exposed condition of the mucosa. 

Among the methods used for this purpose are multiple scarifica- 
tions of the edges of the perforation, removal of the thickened edges 
by the knife, silver nitrate cautery or galvanocautery ; but they are 
seldom attended with success. Berthold succeeded in closing small 
and middle-sized perforations by a process of skin transplantation which 
he called "myringoplastic." The method most frequently applied 
consists in cauterizing the edges of the aperture with trichloracetic 
acid. This substance was discovered by Domas in 1839, but it was not 
until 1889 that v. Stein called attention to its caustic and astringent 
properties at the Paris Medical Congress of that year. Baratoux (Paris) 
first used it for closure of dry perforations of the tympanic membrane. 
In 1895 Oknuff again called attention to this remedy and especially to 
its value in the scarification of tympanic perforations. 

Gomperz and Wassmund recommend cauterization with a con- 
centrated trichloracetic acid resulting from fluidification of the crystal- 
lized substance; Urbantschitsch and Biehl recommend 10-50 per cent, 
solutions. A cotton plug immersed in a 10 per cent, sterile cocaine 
solution is placed to the remnant of the tympanic membrane for 10 
minutes; next the edges of the perforation are touched with a little 
cotton immersed in the solution and fastened to the tip of a probe. 
This will cause a whitish corrosive scab, sometimes accompanied by 
hypersemia of the tympanic membrane and more or less violent pain. 
In some cases a mucous or serous secretion follows the operation. Fur- 
ther cauterization is only permitted after all reactions have subsided. 
Generally speaking, the cauterization should not be done oftener than 
in intervals of five to eight days. According to the size of the aperture, 
closure will occur after three to fifteen applications. Should a crust form 
at the margin of the perforation, it will have to be removed with a pincet 
or probe before cauterization is repeated. 

In case of considerable induration of the margins, it is advisable, 
according to Miot, to apply galvanocautery or to make multiple radial 
incisions prior to the application of trichloracetic acid. The same author 
advises to protect the newly-formed scar from tearing in the first few 
weeks by inserting a cotton plug and interdicting forced expiration. 
Heermann recommends scarlet-red salve to effect a reduction of tym- 
panic perforations, this substance leading, according to his observations, 



AFFECTIONS OF THE MIDDLE EAR 187 

to progressive growth of the tympanic membrane within a few days — 
so much so that he had to interrupt the treatment in order not to pro- 
duce exaggerated irritation. In other cases he found it advantageous 
to extend the irritation to the rest of the tissue elements by additional 
applications. 

All these procedures can be successful only after the pathological 
process of the middle ear has entirely run its course. Premature cauter- 
ization leads almost invariably to rekindling of the inflammatory proc- 
ess. It should further be considered that in many cases the cicatricial 
closure does not constitute an improvement, but a deterioration of the 
auditory acuity, which is even liable to cause subjective ear noises. 
Politzer recommends that, previous to closure of a perforation, small 
perforations should be tentatively filled up with a little drop of diluted 
glycerin, larger ones closed with a moist piece of sterile tissue paper, 
and then the hearing acuity be tested. The result will show the success 
to be expected. Should the hearing acuity be less than with the open per- 
foration, or should there be ear noises, the aperture should not be closed. 

(d) Endotympanic Measures. — While a chronic middle-ear sup- 
puration is in the process of healing, scabs or multiple cicatrices may 
develop in the middle ear. In other cases there may be adhesions (syn- 
echia?) between the manubrium or remnant of the tympanic membrane 
and the middle wall of the tympanic cavity, especially in the region of 
the promontory. With an intact or nearly intact labyrinth, endotym- 
panic incision of the cicatrices or removal of the synechia? in these cases 
may lead to considerable and permanent improvement of the hearing 
acuity. Should the windows of the labyrinth be covered with pathologic 
connective-tissue layers, resection or removal of the latter in the region 
of the cochlear or vestibular window often has a strikingly favorable 
effect upon the auditory acuity. 

Gomperz divides the adhesions between the edges of the perfora- 
tion and the wall of the tympanic cavity with a synechotome, and after- 
ward cauterizes the edges with trichloracetic acid, with the result of 
effecting a considerable improvement in hearing. 

(e) Artificial Tympanic Membranes. — Should the attempt at clos- 
ing the perforation be unsuccessful or the membrane be entirely absent, 
the insertion of an artificial membrane may be resorted to, provided a 
preceding funnel test has shown that an improvement in hearing will 
result therefrom. 

Tonybee's artificial membrane, which is intended to close persist- 
ing gaps, consists of a round rubber disk of 6-7 mm. in diameter; it is 
provided with a silver conduction wire. 

Lucae devised a complete rubber membrane, with a flexible rubber 
handle instead of a silver wire. 



188 THE DISEASES OF CHILDREN 

Lochner draws a fine silver wire or thread through the artificial 
membrane and inserts the latter through Hinton's tube. 

Politzer splits a rubber draining tube in two and attaches a self- 
made wire handle. 

Gruber devised an apparatus for punching out artificial membranes 
from linen, silk, or rubber, the disks being provided with a silk thread 
and inserted with a specially devised forceps. The silk thread remains 
in the auditory meatus and facilitates removal. 

Hartmann recommends membranes made of fish-bone fibres, Katz 
such of celloidin which are made by pouring a 10 per cent, celloidin 
solution upon a glass or porcelain plate. 

Yearsley-Erhard's cotton-wool membrane is very simple and easily 
applied. A small cotton plug, moistened with sterile vaseline or menthol- 
glycerin, is pressed against the perforation or stapes region under guid- 
ance of the speculum. 

Mather advises saturation of the cotton plug with a mixture of 
carbolic acid, glycerin and alcohol ; Baumgarten says that saturation of 
the plug with cocaine would tend to contract the vessels, reduce the 
swelling of the mucosa, and thereby improve the vibration of the auric- 
ular ossicles. 

Urbantschitsch prefers a bland solution (such as salicylic acid 0.2, 
boric acid 0.3, aq. dest. 20.0, or in Yi per cent, menthol-vaseline), the 
cotton plug to be saturated and expressed before insertion. 

Hassenstein's cotton carrier, 2 x /i cm. long, which can be left in the 
external meatus, or Delstanche's cotton brush twisted upon a thin metal 
wire, can be inserted and removed by the patient himself. 

Gomperz advised artificial membranes of vaseline-paraffin, and 
later such of chemically pure silver foil. The latter are sterilized and 
introduced in the most favorable position either dry or moistened with 
a 5 per cent, menthol-vaseline oil. Their advantages consist in being 
non-irritable, pliable, easily sterilizable, and chemically stable. 

Alt uses Gomperz's silver foil, but immerses it in sterile water, 
from which he fetches it out in the shape of a little lump by means of a 
boiled forceps. It is then heated over a gas flame until it is nearly water- 
free, inserted into the tympanic cavity through a speculum, pressed 
against the promontory wall with burnt cotton, and spread at the prom- 
ontory with a sterilized sound. By this method the artificial membrane is 
nearly always tolerated without giving rise to reactions. After the radical 
operation it may remain in the ear for months, provided the new epidermal 
layer of the tympanic mucous membrane has been well developed. 

According to Hamm's method, a small piece of sterilized gauze, 
the size of the tympanic gap, is immersed in molten hard paraffin (melt- 
ing point 113° F.) and inserted into the gap. 



AFFECTIONS OF THE MIDDLE EAR 189 

Where an artificial membrane cannot be applied owing to the 
perforation not being marginal, Hammerschlag instils a few drops of 
vaseline oil into the ear, the head being laterally inclined, and follows 
this up by air insufflation. The latter causes the liquid to enter the 
tympanic cavity where it renders service as an artificial membrane. 
The liquid remains in place for a tolerably long time, owing to capillary 
attraction in cases where the margin of the tympanic membrane has 
been preserved. 

I am in the- habit of using soft rubber caps which the patient can 
himself insert or remove with a forceps. 

The effect of the artificial tympanic membranes upon the hearing 
ability varies considerably, depending not only upon the degree of the 
pathologic changes remaining after the middle-ear affection has healed, 
but also upon the functional sufficiency of the sound-perceiving appa- 
ratus. The effect upon one and the same patient varies according to 
the position of the artificial membrane and the pressure it exercises. 
Considering that the artificial membrane is really a foreign body, it is 
intelligible that the ear must get accustomed to it. An initial unfavor- 
able result should, therefore, not prevent a renewal of the attempt. By 
dint of practice patients often learn to find the correct spot of applica- 
tion themselves. 

In any case it is important to keep the patient under close obser- 
vation for a time, so as to control the functioning of the artificial mem- 
brane. Should there be considerable reaction, the membrane is removed 
until this has disappeared. Slight serous secretions do not necessitate 
abandoning the membrane, but merely its temporary removal until the 
secretion has completely disappeared. In the presence of purulent secre- 
tion as well as in perforation of Shrapnell's membrane, the use of an 
artificial tympanic membrane is to be deprecated. 

Cotton-wool membranes should be renewed daily at first, but later 
on may be left undisturbed for days if no reaction manifests itself. Silver 
appliances, if well tolerated under a suitable system of observatibn, may 
be left in place for weeks or months. 

The permanent use of artificial tympanic membranes is also to be 
considered in cases of chronic middle-ear suppuration with continued 
slight serous or purulent secretion of the middle-ear mucosa, provided 
the auditory acuity, which is bilaterally considerably impaired, experi- 
ences much improvement by their application. Thus, cases of bilateral 
chronic middle-ear suppuration are by no means rare where children 
attain sufficient hearing ability to follow the school instruction. 

Gomperz's method of insufflating a layer of boric acid has been 
successful in many cases. It is especially suitable in perforations which 
expose the stapes in the radical operation. Its improvement upon the 



190 THE DISEASES OF CHILDREN 

hearing acuity in the presence of a still active secretion, however, will 
require further tests ; should they turn out satisfactory, this method would 
be preferable in these cases to all kinds of artificial membranes. 

The value of artificial tympanic membranes consists not only in 
improving the hearing ability, but also in offering a certain protection 
against renewed infections of the middle ear. Nadoleczny and other 
authors have observed that, in spite of considerable defects, an entirely 
new membrane was formed under the protective covering of the prothesis. 

2. THE SURGICAL FORMS OF CHRONIC MIDDLE-EAR SUPPURATION 

These comprise all such cases where, as a rule, surgical interference 
is required to effect a cure. Some of the lighter cases may certainly 
result in a cure under conservative measures, while the condition in 
other cases may be made bearable if treatment is continued for years 
under incessant control. In the majority of cases, however, the suppu- 
ration continues to spread in spite of conservative treatment, with the 
imminent danger of a sudden or insidious occurrence of a complication. 

Complications of middle-ear suppuration resulting from the puru- 
lent inflammatory process spreading beyond the normal anatomical area 
of the middle ear lead to (1) suppuration of the labyrinth, (2) extra- 
cranial or (3) endocranial complications. 

(a) Chronic Purulent Osteitis of the Middle Ear 

Chronic purulent inflammation of the temporal bone always occurs 
under the picture of chronic middle-ear suppuration. 

Anatomy. — The secretion in the chronic stage of acute middle-ear 
suppuration may be confined for a long time to the mucous membrane 
of the middle ear. In that case the anatomical changes consist in ulcer- 
ation and granulation of the mucosa, and later in formation of per- 
manent pathological tissues in the middle-ear spaces (pathological 
ligaments, osteophytes). When the suppuration has led to complete 
destruction of the mucosal integument at circumscribed places, there 
will usually occur purulent inflammation and destruction of the bone 
itself. In the majority of cases such inflammation runs its course under 
the picture of bone caries, less frequently under that of bone necrosis 
with sequestration. The result is purulent decomposition or expulsion 
of the affected parts of the bone. This destructive process is always 
accompanied by new-formation of bone or a considerable thickening of 
the bone in the direct vicinity of the pathologic focus (reactive sclerosis, 
osteosclerosis). Moderate degrees of osteosclerosis are exceedingly fre- 
quent in chronic suppuration of bones. 

In advanced cases of osteosclerosis all the cavities of the mastoid 
are obliterated; the bone turns as hard as ivory; the antrum, the tym- 



AFFECTIONS OF THE MIDDLE EAR 



191 



Fig. 84. 




Ma i 



panic cavity, and the external auditory meatus are considerably con- 
stricted by dense, compact, pathological deposits of bone. These may 
finally lead to complete obliteration (osseous atresia) of the antrum, tym- 
panic tubal ostium, external auditory duct, even the tympanic cavity and 
the labyrinthine window, although the suppuration will persist. 

If the destruction of bone spreads more rapidly, extensive abscesses 
will be formed, filled with stagnating, infectious, and sometimes putrid 
pus. Continued ulceration involves 
the danger of a cholesteatoma of the 
middle ear. 

Spreading of osteitis to the au- 
ricular ossicles, the attic wall, or 
tegmen tympani (Fig. 84) leads to 
sequestration of these parts, exfoli- 
ation, or complete suppurative de- 
struction. 

Symptomatology. — The tym- 
panic membrane is perforated; the 

remnants Of it are thickened by Sequestration .of thetegmen tympani GO of the left 

^ temporal bone in a girl four years old. Death from 
SCarS and Often COVered With a Very aeute Purulent meningitis. Mai, internal auditory 

meatus. 

thick and resisting epidermis. 

The bacteriological examination usually reveals mixed infection. 
Reliable bacteriological finding can only be obtained on the occasion 
of surgical operations of the mastoid by sterile removal of pus from the 
cavities which have previously been closed toward the auditory meatus. 

The pathological picture is dominated by the symptom of chronic 
suppuration. The pus exudes through the auditory meatus, is fetid, 
and retains its fetid character in spite of energetic antiseptic treatment. 
This is due to the anatomic conditions which in chronic osteitis prevent 
free evacuation of the pus, which, being retained in the grooves and 
furrows of the affected, partly destroyed bone, becomes decomposed. 
The danger of purulent stagnation is hardly less great in the tympanic 
cavity and external auditory duct, especially in cases where the mucosa 
of the duct had already been previously affected by chronic eczema or 
ulcerations. Cleansing the middle-ear spaces can only imperfectly be 
done, as, in spite of careful syringing and irrigation with the attic tube 
in typical cases, pus can again be immediately observed in the otoscopic 
field by aspiration. This persistent and often threatening retention of 
pus cannot be overcome by long-continued conservative treatment. 
The secretion may sometimes be restricted for a few days, but after a 
short time a copious evacuation will set in without warning, often under 
the veritable picture of a pus flood. 

As a matter of course, the destruction of bone progresses most 



192 THE DISEASES OF CHILDREN 

rapidly where the bone is thin and tender. Compact osseous substance 
offers more resistance, and thus it comes to pass that in early dissemi- 
nation of suppurative osteitis to the mastoid the internal parts of the 
latter are softened and fluidified at a suprisingly rapid rate, whereas it 
often requires as much as several years to expel or resorb the lateral 
ossicles (malleus, incus), which had long before been affected. Similarly, 
the destruction of the very compact and dense structure of the lateral 
osseous wall of the superior tympanic cavity and antrum requires a long 
time. The final result is the complete destruction of the osseous wall and 
the fistulous perforation of the pus cavity toward the external meatus. 

However, it would be quite a mistake to expect to find in each case 
of osteitis of the middle ear nothing but signs of advancing purulent 
decomposition of the bone, as there is also early osseous new-formation 
and condensation of the normal bone, thick layers of connective tissue 
actually protecting tender bony parts from affection or destruction. In 
many cases, for instance, the lateral ossicles, which consist of rather 
massive and compact bones, are partly or completely destroyed at a 
time when the much tenderer stapes is still intact. This is explained 
by the fact that the middle wall of the tympanic cavity had been covered 
in these cases by early deposits of connective tissue and the corners of 
the labyrinthine windows have been filled with connective tissue. This 
is facilitated in the stapes region by the normal presence of connective- 
tissue bridges which need only extending to cover the stapes completely. 

If the tube has remained large and permeable, the pus is often 
evacuated into the pharyngeal cavity, especially in infants, and the 
fetid odor and taste in the fauces can be perceived by the patients. 
Abundant evacuation through the tube may simulate suppuration of 
the accessory nasal cavities or of the sphenoid bones. 

The auditory acuity is usually much reduced (V-33^-13J^ feet). 

The tuning-fork test shows disturbed perception of high sounds 
aside from the typical signs of an obstacle to sound-conduction as repre- 
sented by the suppuration of the middle ear. The perception of high 
sounds is effected by the vestibular section of the cochlea. The new- 
formation of connective tissue of the internal wall of the tympanic 
cavity passes on to the blind end of the scala tympani in nearly all 
cases of middle-ear suppuration. It is through this net of connective 
tissue that the vibration of the elements of the membranous cochlea is 
interfered with, leading to degeneration of Corti's organ and the acces- 
sory parts of the spiral ganglion and of the cochlear nerves. This is a 
perfectly typical manifestation,' so that the shortened perception of 
high sounds in the transfusion of the pathological process from the meatus 
to the internal ear is often a very characteristic sign of chronic middle- 
ear suppuration. 



AFFECTIONS OF THE MIDDLE EAR 193 

In other somewhat rarer cases of uncomplicated chronic osteitis of 
the middle ear, the occurrence of labyrinthine spontaneous nystagmus 
without vertigo and without equilibrial disturbances must be looked 
upon as a distant effect, the anatomical explanation of which is similar 
to that of the cochlear changes. 

A comparison of the affected with the healthy mastoid will usually 
show a diffuse chronic thickening of the periosteal covering, without 
airy tenderness, either spontaneous or on pressure. The maxillary 
glands, and in neglected cases also the cervical lymph-glands, are en- 
larged, distinctly palpable, and often painful on pressure. There is 
often regional headache, with a sensation of fulness and heaviness in 
the head. The temperature is normal and the general condition in 
adults usually undisturbed. In infancy continuous fetid suppuration 
leads to anorexia and disturbance of nutrition, which finally ends in 
loss of weight, pallor of the mucous membranes, despondency, lassitude, 
dislike of work, and tendency to fatigue. Children are usually back- 
ward in intelligence and make slow progress at school. 

Diagnosis. — The diagnosis of osteitis of the middle ear can some- 
times be made by the demonstration of the affected bone, especially in 
infancy. These are cases of exfoliation of the lateral ossicles, destruc- 
tion of the lateral antrum and attic wall, and sequestration in the antrum 
or at the fundus of the tympanic cavity. The diagnosis is also supported 
by the history of spontaneous evacuation of small pieces of bone or by 
their actual demonstration. 

In a large number of cases, however, indirect symptoms have to be 
resorted to. One of the most reliable is the persistent fetid character 
of the secretion in spite of energetic long-continued antiseptic treatment 
of the middle ear. If, notwithstanding cleansing of the middle-ear spaces, 
rinsing, with subsequent drying up and insufflation of strongly anti- 
septic powders (iodoform), the pus should retain its fetid properties 
after five to eight days' treatment, the conclusion of purulent osteitis 
is justified. Black discoloration of inserted iodoform or xeroform gauze 
strips within twelve hours, in spite of careful cleansing and drainage of 
the middle ear, is also a very valuable sign, though not equally relia- 
ble. Livid discoloration of the internal end of the auditory duct and 
ulcerations of the integument in the region of the osseous duct likewise 
indicate involvement of the bone, and should invariably be responded 
to by a careful search for osseous fistula? with the hook sound and attic 
speculum. Demonstration of an osseous fistula is a sure sign of bone 
suppuration. 

Positive demonstration of purulent osteitis is difficult in cases of 
slight perforation with sparsely flowing, purulent secretion. This par- 
ticularly refers to suppuration of the upper tympanic cavity, but the 

VI— 13 



194 THE DISEASES OF CHILDREN 

persistent fetid character of the pus will again be an important sign. 
Pus retention can in some cases be demonstrated by pus being visible 
or oozing out upon removal of superficial crusts constricting or occlud- 
ing the perforation. 

Course and Result. — Bone suppuration may be arrested in a small 
number of cases by conservative treatment, or spontaneously without 
any treatment whatever. The affected bone is absorbed and heals with 
a connective-tissue scar. There remain no defects except those men- 
tioned as signs of a previous chronic suppurative osteitis, consisting in 
condensation of the bone in the immediate vicinity and connective- 
tissue scars of the medial wall of the tympanic cavity or pathologic 
connective-tissue bridges in the cavity itself. In the majority of cases, 
however, the gap in the tympanic membrane will persist, owing to its 
margin becoming invested with epithelium. In many cases restoration 
does not take place by normal tympanic tissue, but by more or less thin 
scar tissue, connective-tissue scars, or calcified connective tissue (Plate 
VIII). It is not surprising, therefore, that in most cases the hearing 
distance is permanently reduced, and good functional sufficiency after 
chronic osteitis constitutes a rare occurrence. 

In about 80 per cent, of all cases of chronic osteitis of the middle 
ear, suppuration defies all conservative treatment. Middle-ear changes, 
which must be looked upon as initial signs of healing and are demon- 
strable in nearly all cases, are accompanied by progressive dissemination 
of the bone suppuration. The progress in healing, however, does not 
keep step with the progress of the suppuration, the result in the most 
favorable cases being suppuration continued for life within the anatomi- 
cal borders of the middle ear. Gradual degeneration of the nerve- 
terminals of the internal auditory canal finally leads to the highest 
degree of partial or to complete deafness. In other cases the suppura- 
tion of the bone spreads to the surrounding parts, so that in the end 
distant parts of the temporal bone become affected (mastoiditis, ulcera- 
tion of the temporal squama and zygomatic process, suppuration of the 
labyrinth) or a perforation occurs with a descending abscess. The 
ulceration may also spread to the cranial cavity, either direct or by the 
route of the mastoid or labyrinth. This involves an endocranial otitic 
affection. 

Treatment. — When the bone suppuration is superficial, well de- 
marcated, and confined to the tympanic cavity, conservative treatment 
may be successful, provided a spreading of the osseous process can be 
prevented while the treatment is going on. This particularly refers to 
cases where the lateral osseous attic wall, the osseous trabecular of the 
hypotympanum, or the auricular ossicles are affected. In the other cases 
nothing but surgical interference will effect a cure. 



AFFECTIONS OF THE MIDDLE EAR 195 

(b) Cholesteatoma of the Middle Ear 

Anatomy. — Primary and secondary cholesteatomata are to be 
distinguished. The former belongs to the group of congenital tumors 
and owes its existence to displaced embryonal epidermal germs which 
independently continue to grow. Primary cholesteatoma in the ear 
has only been observed in very rare cases as a congenital cholesteatoma 
of the dura mater which has spread to the ear by gradual increase in 
size. 

Secondary cholesteatoma of the middle ear (Figs. 85-88) demands 
great clinical interest, as it never occurs except in the wake of chronic 
middle-ear suppuration. It may be briefly termed cholesteatoma, and 
its evolution takes place in the following manner: The epidermal layer 
of the external auditory duct gradually grows into the middle ear, either 
direct or by the aid of misplaced isolated epidermal islands, while the 
middle-ear suppuration continues. Owing to the presence of an otor- 
rhcea, which may have existed for many years, the epidermal layer of 
the auditory duct, especially at its internal end, develops pathologic 
proliferation. Penetration of this rapidly proliferating epidermis into 
the middle-ear space is facilitated and rendered possible by (1) marginal 
perforation or complete destruction of the tympanic membrane, (2) 
perforation of Shrapnell's membrane and defects of the lateral attic 
and antrum wall. 

The fact of the epidermis advancing into the middle-ear spaces 
does not necessarily lead to the formation of a cholesteatoma; in fact, 
as the epidermis advances into the middle ear, it may occasionally pro- 
duce a cure of a chronic middle-ear suppuration by furnishing the re- 
quired epidermal material. This is particularly the case in simple 
chronic middle-ear suppuration where the osseous parts of the middle 
ear have been preserved. If, however, the bone is affected, the pene- 
trating epidermis will soon degenerate into pathologic proliferation, 
owing to the continuation of the suppuration. In the course of this 
process, isolated epidermal groups may be displaced underneath the 
surface between the granulation wall and the bone, where they continue 
to grow independently. The unavoidable consequence is the formation 
of epidermal balls, consisting of concentric epidermal layers (Figs. 86, 87). 
Their central parts are composed of macerated cell masses, profuse 
quantities of detritus, micro-organisms, fat crystals, and cholesterin 
crystals. The superficial layers (Figs. 85, 88) of the cholesteatoma 
(matrix) are more intensely proliferated. The development of the 
superficial epidermal layer is so intense that the soft parts as well as the 
bone are completely destroyed as the cholesteatoma increases in size. 
The organic substance of the bone perishes; the inorganic salts are de- 
posited in the nearest bone in the vicinity. This bone, being thus dis- 



196 



THE DISEASES OF CHILDREN 



Fig. 85. 



Mai 



tinguished by a superabundance of lime, joins in the proliferation. As 
a consequence, a very dense osseous layer, as hard as ivory, forms around 
the cholesteatoma, and even the macerated specimen shows the smooth 
demarcation of the cavity (Fig. 88), as distinguished from the furrowed, 
ribbed bone cavity after caries and sequestration. 

Renewed infection of the cholesteatoma, which usually occurs dur- 
ing an acute exacerbation of chronic middle-ear suppuration, is the 

cause of exceedingly dangerous, acute 
putrefaction of the cholesteatoma 
(Fig. 85). 

Symptoms. — In typical cases 
there is a profuse discharge of highly 
fetid pus, permeated with white 
crumbs and grayish-yellow epidermal 
masses. If the cholesteatoma has 
been destroyed by acute putrefac- 
tion, large numbers of particles are 
removed through the external meatus. 
In other cases particles of the choles- 
teatoma can be recognized in the 
otoscopic picture by their grayish- 
white color and the stratified struc- 
ture of the tumor. In some cases 
cholesteatoma gives rise to no special 
manifestations; in the others the 
otoscopic picture shows an appar- 
ently healed middle-ear suppuration, 
and nothing but the periodical return 
of the suppuration, as elicited by the 
history, points to the continuance of 
the pathological process. In choles- 
teatoma of the antrum the posterior 
wall of the auditory duct has con- 
siderably descended ; if the attic wall 
is destroyed, a cholesteatoma of the 
attic may be freely visible in the otoscope. Should the cholesteatoma 
have grown beyond the borders of the middle ear and led to complica- 
tions, it is the clinical manifestations of the latter which suddenly spring 
into view. For the symptomatology see the corresponding chapter (pp. 
234-275). 

Diagnosis. — The diagnosis of cholesteatoma may in some cases be 
made from the above-described peculiarities of the suppuration or from 
the otoscopic findings. Defects of the osseous wall of the auditory duct 




Cholesteatoma of the middle ear and labyrinth. 
Right temporal bone. The central part of the cho- 
lesteatoma is decomposed and spontaneously ex- 
pelled. The peripheral layers and the matrix are 
firmly attached and sharply contrast against the 
green color of the bone by their yellow-gray color 
and mother-of-pearl lustre. The contrasting colors 
of the specimen are the result of preservation in 
Miiller's fluid and subsequent treatment with alco- 
hol. The cut surface corresponds to a vertical sec- 
tion through the temporal bone in the region of the 
tympanic cavity near the antrum. The cholestea- 
toma has led to three fistula? in different directions: 
(1) fistula through the tegmen tympani to the dura 
of the middle cranial fossa; (2) complete suppura- 
tive destruction of the labyrinth with fistulous 
eruption into the internal auditory duct (Mai); 
(3) fistulous eruption through the lateral wall of the 
mastoid process (M). Observe the condensation 
of the entire preserved part of the bone. (Natural 
size.) Boy thirteen years old. Death from diffuse 
purulent meningitis. 



AFFECTIONS OF THE MIDDLE EAR 



197 



and signs of mastoiditis in chronic middle-ear suppuration likewise 
point to cholesteatoma. An exact clinical diagnosis, however, can be 
made only by a microscopic examination of the pus taken from the mid- 
dle ear. 

For this purpose the external auditory duct is carefully cleansed 
with benzine and a 5 per cent, perhydrol solution, special attention being 
paid to the cleansing of the angle and fundus. Some pus is expelled 
from the middle ear by irrigation with the aid of an attic tube, spread on 
a slide in physiological salt solution, and examined while fresh. With 
medium microscopic enlargement the characteristic cholesterin crystals 



Fig. 86. 




M o Hy 

Frontal longitudinal section through the right temporal bone. Cholesteatoma of the middle ear and 
labyrinth. Posterior half of the section. (Natural size.) A cholesteatoma about the size of a cherry fills the 
upper part of the mastoid process (M). The bone in the vicinity (o) is condensed. Cholesteatomatous masses 
fill the hypotympanum (Hy) and have advanced into the labyrinth (Css, Co). Css, canalissemicircularis supe- 
rior; Co, cochlea; Mai, meatus auditorius internus; Cc, canalis caroticus. 

will be found, which may number up to 100 in one field of vision, es- 
pecially if the cholesteatoma has putrefied; in other cases only a few 
crystals may be present. 

The cholesterin test may prove negative in spite of the presence of 
a cholesteatoma if the latter is covered by granulations, or the auditory 
duct is occluded by polypi, and in cases where the irrigation fluid cannot 
reach the cholesteatoma owing to pathological changes in the external 
or middle ear. 

Course. — In most untreated cases the course is unfavorable, owing 
to the constant increase in size as well as to the possibility of sudden 
putrefaction. The latter contingency is fraught with special danger 
if the cholesteatoma has already exposed the dura or advanced up to 
the cavities of the labyrinth. Acute putrefaction of a cholesteatoma is 



198 



THE DISEASES OF CHILDREN 



responsible for at least 60 per cent, of all endocranial otogenous affec- 
tions and for many cases of otogenic paralysis of the facial nerve and 
suppuration of the labyrinth. 



Fig. 87. 




Frontal longitudinal section through the right temporal bone. Cholesteatoma of the middle ear and 
labyrinth. Anterior half of section. (Natural size.) T, auditory canal; Ty, tympanic cavity; V, vesti- 
bule; Ch, Mastoid cells filled with cholesteatoma; P, promontory; Co, cochlea; Mai, meatus auditorius 
internus. 

The subjective and objective manifestations may be reduced to 
bearable proportions by conservative treatment in a number of cases, 
but complete and permanent recovery is only exceptionally possible by 
conservative treatment. 

Fig. 88. 




Cholesteatoma cavity (Cho) of the mastoid process. Right temporal bone seen from the posterior surface 
of the petrous bone (Mai, meatus acustieus internus). Observe the mother-of-pearl lustre of the smooth matrix 
of the cholesteatoma (Cho). 1 and 2 are fistulous perforations through the lateral wall of the mastoid; 3 is a 
fistulous opening of the middle cranial fossa. The cavity is wide open toward the posterior cranial fossa owing 
to the large osseous defect. Death occurred from infectious sinus thrombosis and pyaemia. (Natural size.) 



The surgical treatment consists in the radical operation. Attico-an- 
trotomy and plastic of the auditory duct are done in well-demarcated 
cholesteatoma of the attic or antrum where there is good hearing acuity. 



AFFECTIONS OF THE MIDDLE EAR 199 

Indications. — A relative indication for operation exists in all cases 
of established cholesteatoma of the middle ear with normal or at least 
good hearing acuity of the opposite side. Operation is contraindicated 
in partial or complete deafness of the other ear and in constitutional 
affections. 

An absolute indication -for operation exists in cases where the choles- 
teatoma has led to paralysis of the facial nerve and where there are 
clinical signs pointing to erosion of the capsule of the labyrinth or to 
exposure of the dura mater or sinus. 

(c) Chronic Middle-ear Suppuration Complicated by Ulceration and 
Stenosis of the External Auditory Canal 

This is not amenable to conservative treatment. Formation of 
fistulse in the osseous external duct is usually observed when the osseous 
wall has been destroyed by the proliferating cholesteatoma. Ulceration 
of the posteriosuperior part of the auditory duct always gives rise to the 
suspicion of a fistula which can be verified by the sound. X-ray photog- 
raphy also renders good service in some cases. 

Removal of granulations and polypi from the external duct is usually 
useless, as their recrudescence cannot be prevented in spite of continued 
conservative treatment. Operative treatment is even more indicated, 
as it is just purulent osteitis of the middle ear which leads to ulceration 
of the auditory duct. 

(d) Chronic Middle-ear Suppuration Complicated by Purulent Mastoiditis 

Purulent inflammation of the mastoid process sometimes develops 
insidiously in the course of a chronic middle-ear suppuration. Per- 
iostitic, painless thickening of the covers of the soft mastoid parts is a 
prodromal symptom. Such forms of inflammation as resemble acute 
purulent mastoiditis in the course of acute middle-ear inflammation 
will only occur if there has been sequestration of the mastoid or acute 
putrefaction of the antrum and mastoid in the course of chronic middle- 
ear suppuration. 

In these cases the symptoms of mastoiditis are caused by accumu- 
lation of pus in the mastoid (chronic empyema), by sequestration or 
ulceration of a cholesteatoma; they are often complicated by sinus 
thrombosis and pachymeningitis. Nothing but timely radical operation 
offers a chance for recovery. 

Fistulous perforation into the osseous external duct will occur after 
mastoiditis or suppuration of the antrum has existed for some time, 
especially in the presence of a cholesteatoma. Destruction of the osseous 
wall continues uninterrupted, the final result being complete destruction 
of the posterior and superior parts (natural radical operation). These 



200 THE DISEASES OF CHILDREN 

cases may recover spontaneously after a radical operation, or under 
conservative treatment directed to the re-formation of epidermis in 
the middle-ear spaces, but they are exceptions. In all other cases the 
middle-ear suppuration can only be arrested and vital complications 
prevented by timely radical operation. 

(e) Chronic Suppuration of the Upper Tympanic Cavity (Epitympanum or 
Attic). Chronic Suppuration of the Antrum 

Owing to the topographical position of the auricular ossicles, their 
muscles and ligaments, the meso- and epitympanum normally com- 
municate by fissures. The communication between the meso- and epi- 
tympanum may be completely interrupted by the formation of abnormal 
ligaments and abnormal connective-tissue layers at the point of commun- 
ication, owing to catarrhal affections of the middle ear. The lowest 
part of the epitympanum in the normal upright position of the head is 
formed by ShrapnelPs membrane, and the small aperture of the latter 
is the only way of escape for the pus formed in suppurative inflammation 
owing to interrupted communication between the meso- and epitym- 
panum. Thus epitympanic suppuration is one of the most dangerous 
forms of middle-ear suppuration, and tends to early chronicity and 
failure of conservative treatment. Furthermore, perforation of Shrap- 
nell's membrane favors the formation of a cholesteatoma of the middle 
ear, and, owing to the smallness of the membrane, the perforation soon 
extends to the osseous margin. A cholesteatoma of the attic or antrum 
may easily develop, considering that Shrapnell's membrane has a thick 
epidermal layer of its own with papillary rudiments, and that a patho- 
logical proliferation of the epidermis must unavoidably cause the latter 
to grow into the upper tympanic cavity or into the antrum. 

Symptoms. — Suppuration of the attic and antrum is characterized 
by the insidious nature of its onset and course. There is no pain what- 
ever in the incipient stages. If the hearing acuity is but slightly impaired 
and that of the other ear normal, the affection may remain undetected 
for a long time, until there is suddenly a purulent secretion from the 
external meatus. Further dissemination of the purulent inflammation 
may cause earache and headache. Extension of the process to the chain 
of auricular ossicles usually injures the hearing acuity to a considerable 
extent. In pus retention there is headache in the temporal region of 
the affected side, susceptibility to percussion in the temporal region, 
and sometimes moderate elevation of temperature. 

The conditions of the tympanic membrane cannot be mistaken 
in most cases (Fig. 89). The seat of the affection is usually marked 
by a small shiny drop of fluid covering the region of Shrapnell's 
membrane. On removing the secretion with cotton tips, a slightly 



AFFECTIONS OF THE MIDDLE EAR 



201 



Fig. 89. 




Tympanic mem- 
brane in chronic 
epitympanic mid- 
dle-ear suppura- 
tion. Perforation of 
the right membrane 
of Shrapnell. 



granulated surface will be seen in some cases, a granulation-polypus 
growing out of the perforation gap in others. Where the secretion is 
slight, the perforation may be closed by a brown ceruminal crust, on 
removal of which pus becomes visible. It is certainly necessary in all 
cases of affections of the ear to establish carefully the exact condition 
of the membrana flaccida. If the lateral osseous wall is destroyed by 
ulceration, the otoscope will reveal a more or less extensive gap, through 
which the attic and the parts of the auricular ossicles situated therein 
become plainly visible (Fig. 90, 1). If the auricular 
ossicles are destroyed, the attic is either empty or 
replete with granulations. In these cases atticoscopy in 
conjunction with the attic speculum, recommended by 
Urbantschitsch, renders excellent service in the examina- 
tion of the attic and antrum. 

The parts of the auricular ossicles situated in the attic 
are either primarily affected, or secondarily by the spread- 
ing of the attic suppuration. 

Pus retention in the attic and antrum not infre- 
quently leads to descent of the posterior wall of the audi- 
tory duct. Besides, fetid pus may be seen to exude shortly after the 
middle ear has been cleansed, although sometimes it only appears upon 
aspiration with Siegle's irrigation apparatus. 

The upper tympanic cavity is separated 
from the middle cranial fossa by the tegmen 
tympani, and pus retention in the former 
favors spreading of the purulent inflammation 
to the latter. 

Tuberculosis of the middle ear (q.v.) begins 
in a fair number of cases under the picture of 
torpid suppuration of the attic or antrum. 

Suppuration of the antrum as well as of the 
attic often sets in without any symptoms. The 
perforation may be situated in the postero- 
superior quadrant (Plate VIII, 12; Fig. 90, 2) 
or in the auditory duct itself. In the latter case it may be difficult to 
recognize it in direct otoscopy, and its presence should therefore be care- 
fully established by a curved sound and aspiration of purulent secretion 
with Siegle's irrigation apparatus. 

Treatment. — Conservative treatment leads to recovery in some 
cases where the ulceration is well demarcated. In caries of the au- 
ricular ossicles, ossiculectomy is often effective, provided the middle- 
ear spaces are otherwise normal. In all other cases radical opera- 
tion is indicated, especially in the presence of a cholesteatoma of the 



Fig. 90. 




1. Chronic attic suppuration with 
destruction of the lateral attic 
wall. 2. Chronic antrum suppura- 
tion with destruction of the lateral 
antrum wall. 



202 THE DISEASES OF CHILDREN 

attic or antrum. Where there is good hearing acuity and a perfectly 
normal meso- and hypotympanum, attico-antrotomy may suffice. 

OPERATIVE TREATMENT OF THE SURGICAL FORMS OF CHRONIC MIDDLE- 
EAR SUPPURATION. 

1 . Excision of Malleus and Incus (Ossiculectomy) 

The operation is done under local injection anaesthesia. The mal- 
leus is circumcised with a narrow little knife and slowly mobilized with 
a small forceps. When sufficiently mobilized, it is firmly grasped with 
an ear-forceps or the Sexton forceps (double-hook forceps), pulled out 
downward, and extracted. Delstanche's circular knife cannot be rec- 
ommended for this operation, as it easily fractures the crura of the stapes 
or may dislocate the stapes itself. Should the malleus and incus be 
united either by pathologic connective-tissue layers or bone, both are 
extracted together. In other cases it will be necessary first to draw 
the incus downward with the forceps or to deflect the same from the 
antrum to the mesotympanum with the aid of small sharp spoons. 
This operation requires practice and caution, and previous experience. 
A careful examination with the probe or attic speculum should have 
positively established the normal site of the incus. In many cases of 
antrum suppuration the incus is destroyed, and nothing but malleus 
and stapes remain. 

Rough procedure in extracting the incus may lead to injury of the 
osseous facialis canal and paralysis of the facial nerve, and even luxation 
of the stapes. It need not be specially mentioned that the auricular 
ossicles must not be extracted if there are signs of impending labyrinth 
affection. The wound caused by the extraction has to be carefully 
tamponed with iodoform wicks and bandaged. If the patient is free 
from fever and pain, the bandage remains undisturbed for four days. 
On the fourth day the wicks are pulled forward one by one, shortened 
by half their length, and completely removed on the following day. 

2. The Various Methods of Performing the Radical Operation. (Operative 
Exposure of the Middle-ear Spaces) 

The object of the operative exposure of the middle-ear spaces is to 
unite the various cavities of the external and middle ear into one uniform 
traumatic cavity without sharp projections, deep sinuses, or angles, so 
far as such may be possible. 

In those cases of chronic middle-ear suppuration in which the mas- 
toid process does not show any signs of suppurative inflammation it 
will be sufficient to unite the antrum, hypo-, meso-, and epitympanum 
and the external auditory canal by removing the various septa. The 



AFFECTIONS OF THE MIDDLE EAR 



203 



mastoid cells are opened and removed with the chisel only as far as may 
be necessary for opening of antrum and removal of the posterior osseous 
wall of the auditory duct (conservative exposure of the middle-ear 
spaces ; synonyms : radical operation after Zauf al ; radical operation after 
Stacke). 

In the radical operation performed by Zaufal the antrum is exposed 
with the chisel, starting from the antrum triangle (Fig. 79), after which 
the presenting posterior osseous wall of the auditory duct is removed. 
In the radical operation recommended by Stacke, which is but seldom 
resorted to in children, the chisel work commences with the removal of 



Fig. 91. 




. Eal 



„.' Ss 



M 



Topography of the middle ear after exposure of the middle-ear spaces and opening of the canalis facialis and 
of the lateral semicircular duct. (Left temporal bone, § natural size.) Eal, eminentia arcuata lateralis (opened); 
M, mastoid process; Pro, promontory; 5s, sulcus sigmoideus; Fc, fenestra cochleae; Cvii, canalis facialis. 

the posterosuperior osseous wall of the auditory duct. In every conserv- 
ative exposure the middle-ear spaces are to be opened outwardly far 
enough to prevent any retention of secretion or pocket formation. Special 
care should therefore be taken to remove completely the lateral osseous 
attic wall (Fig. 91). 

The osseous crest, demarcating the hypotympanum, is likewise 
completely removed, so that the fundus of the osseous external audi- 
tory duct may continue into the osseous fundus of the tympanic cavity 
on precisely the same level. With the object of obliterating the tube, 
its mucous membrane is curetted. Whenever the tympanic cavity be- 
comes pointedly funnel-shaped toward the tubal opening, it would be 
advantageous to attenuate or remoVe the anterior part of the tympanic 
membrane with the chisel or the bone-forceps. This will effectually 
serve to prevent the formation of a fistula or funnel at the tubal open- 
ing, at the same time favoring the formation of a solid cicatricial occlu- 



204 THE DISEASES OF CHILDREN 

sion of the tube. The posterior wall of the osseous auditory duct is 
opened up to the facial canal, except that a slightly protruding convex 
crest remains (Fig. 92). Sufficient removal is attained if the upper end 
of the facial region does not lie higher than the prominence of the 
lateral semicircular duct. The basal inferior part, however, should only 
be removed far enough to allow the promontory to be seen at a lateral 
aspect. On the other hand, the window of the cochlea should be invisible 
in the position the examiner now occupies. Should it be present in the 
field of vision, it would indicate that too much bone has been chiselled 
away in the facial region and the facial nerve has been endangered. 

The exposed cavities are cleansed with sharp spoons and curetted, 
abstaining of course from any curettage whatever of the lateral wall of 
the labyrinth. Rough mopping and any force whatever should be 
avoided; any slight hemorrhage, even though disturbing, is best checked 
by the insertion of adrenalin tips rather than by repeated mopping of 
the traumatic cavity, as the latter proceeding may endanger the stapes. 

In chronic cases, where the hollow cavities of the mastoid process 
are involved in the suppurative osseous affection, all the spaces of the 
mastoid process are to be opened as well (Fig. 91). This is the typical 
radical operation or radical exposure of the middle-ear spaces (synonym : 
radical operation after Kuester-Bergmann) . In this operation we start 
from the mastoid triangle (Fig. 79), carry out the exposure after the 
type of the conservative method of operation above described, after 
which the osseous contents of the mastoid itself are removed. But 
whether the exposure has been performed according to the conserva- 
tive or radical method, it is important that the smoothing out of the 
osseous parts toward the middle cranial fossa and the sigmoid sinus be 
reserved for the final act of the operation, so as to obviate the necessity 
of carrying through the entire ear operation with the exposed dura of 
the middle cranial fossa or with the exposed and possibly bleeding sinus. 
Accidents of this kind cannot be prevented by the most experienced. 

Owing to the removal of the posterior osseous wall of the auditory 
canal, the membranous canal remains in the shape of a cartilagino- 
membranous soft tube, which protrudes into the traumatic cavity and 
is now, after the operative exposure of the middle-ear spaces, inserted 
merely at the tympanic membrane along the anterior wall of the audi- 
tory duct. The fate of such a soft ear would be suppurative disintegra- 
tion in the course of the traumatic process, ending with cicatricial stric- 
ture. It is necessary, therefore, to supply the membranous auditory 
duct with a plastic support after every radical operation. 

The incisions necessary to supply the plastic support may vary 
(Fig. 92). Panse applies a T-shaped incision. If the longitudinal in- 
cision were not made in the middle, but toward the upper or lower end 



AFFECTIONS OF THE MIDDLE EAR 



205 



Fig. 92. 



Eal 



,- St a 



of the vertical incision, one single flap would be obtained, the base of 
which would be situated either upward or downward. On the other 
hand, in Panse's plastic operation there will be an upper and a lower 
flap. In these three methods there will be a very spacious auditory 
meatus, which, however, is demarcated by a traumatic line at its pos- 
terior half. This may give rise to difficulties in the after-treatment and 
lead to a stricture of the auditory meatus. In cases where the vertical 
incision lies very far laterally, exposing the cartilage, there will also be 
danger of suppurative perichondritis. 

It is not surprising, therefore, that these methods have undergone 
modifications. Briihl leaves a square flap at the auditory meatus, 
Siebenmann (Fig. 92) and Neumann a triangular flap which can be drawn 
backward by a catgut suture. In this 
way the remaining auditory meatus is 
entirely surrounded by epidermis, so that 
there can be no question of perichondri- 
tis, as any cartilage which should be ex- 
posed will be at once plastically covered. 

The methods so far mentioned are 
principally devoted to the formation of a 
convenient auditory meatus. But the 
resulting flaps are relatively short, with 
a broad base, which can advance but 
little into the operative cavity. The 
healing of the operative trauma occurs 
by the bone being gradually covered 
with epidermal epithelium, while the os- 
seous cavity itself will persist. The de- 
tails of the healing process will again be 
referred to, and at this juncture it may 
merely be mentioned that it is important 
to advance the epidermal flaps from the 
first as far as possible into the osseous 
cavity, since it is from these flaps that 
the growth of the epidermal layer leading to a cure will take its start. 

From this stand-point we ought to try to obtain very long flaps 
with a narrow base. Koerner's plastic operation (Fig. 92) is the closest 
approach to this demand, but the long tongue-shaped flap is suitable 
only for cases in which healing without reaction can be foreseen during 
the operation and the retro-auricular wound immediately closed up to a 
small aperture at the lower traumatic angle. For the other cases Pas- 
sow's plastic operation is best adapted, especially where the traumatic 
cavities are large, in cases of an exposed posterior cranial fossa, in cases 




Pro 



View of the operative field after complete 
conservative exposure of the middle-ear 
spaces (radical operation after Zaufal). (Left 
ear, § natural size.) Tu, tympanic tubal open- 
ing; Cf, canalis facialis; Eal, eminentia arcuata 
lateralis; Pro, promontory; F, smoothed-out 
facialis spur; aa, incision after Koerner's 
plastic; b, incision after Panse; e, incision 
after Siebenmann; Sta, stapes. 



206 THE DISEASES OF CHILDREN 

of sinus thrombosis, and in cases of total suppuration of the mastoid 
process. With this operation the flaps are certain to remain attached 
to the traumatic cavity, while pocket formation is excluded. 

If the auditory canal was ample, we shall confine ourselves to the 
skin of the canal and not incise beyond the meatus. In the opposite 
case there is danger that after closure of the retro-auricular wound — 
which we should always endeavor to effect — the auditory meatus will 
not be sufficient for the after-treatment or for the necessary control of 
the traumatic cavity. In cases of this kind the auditory meatus may be 
enlarged by prolonging the incisions into the cymba conchae or, as the 
case may be, continue the lateral incisions beyond the normal auditory 
meatus. On the other hand, too large a meatus will later result in a con- 
siderable deformity, and this contingency should be avoided, as it is 
entirely unnecessary. For this reason, I am unable to endorse the propo- 
sition of some authors to incise the cartilage of the auditory duct and 
the concha in order to obtain an exaggerated meatus. 

The fate of the retro-auricular traumatic cavity depends upon the 
peculiarities of each case. Where an entirely uncomplicated healing 
process can be foreseen, the retro-auricular wound is closed down to 
the lower traumatic angle immediately after the operation. Mitchell's 
clamps are best for this purpose. Only a few wicks from the antrum 
region are conducted outward through the lower angle. These are cases 
which previous to the operation did not show any signs of the surround- 
ing parts being affected and in which the operation confirmed that the 
suppurative inflammation had been entirely confined to the middle ear. 

In some clinically uncomplicated cases, however, it may be seen at 
the operation that the bone is diseased up to the dura, most frequently 
at the middle cranial fossa, so that the dura, although not affected, lies 
exposed in the operative cavity. In cases of this kind as well as in cases 
where a venous sinus has been exposed, I am in the habit of narrowing 
the retro-auricular skin wound by suture clamps, but allowing a bundle 
of wicks about the thickness of a little finger to protrude on the outside. 
In cases complicated by endocranial or labyrinthine involvement the 
retro-auricular suture had better be avoided; in extensive incisions (in 
cases of sinus thrombosis) the skin flaps can only be approximated by a 
bridle suture. 

After-Treatment Following Radical Operation.— The first bandage 
covers half the head, including the neck. In cases which run a normal 
course the bandage is changed on the sixth day. All gauze layers 
are removed to the wicks; the latter are pulled out by about 2 cm. 
and shortened. 

After that the bandage is changed every second day, and wicks are 
gradually shortened. 



AFFECTIONS OF THE MIDDLE EAR 207 

In wounds of medium size all the wicks are usually removed with 
the fourth change of bandage. The wicks are to be pulled out very 
carefully, each one being caught separately with the forceps and handled 
with the greatest care. In this way the patient is saved unnecessary 
pain, and the cavity will not be subjected to any unnecessary trauma. 
If the bandages have been changed with the necessary care, there will 
be no hemorrhage as the wicks are being removed. 

In the further course the frequency of the changes will depend upon 
the quantity of the traumatic secretion, which differs considerably in 
various cases. The bandage must not be allowed to remain after it is 
no longer effective. The change of bandage, if done at the proper time, 
will show the outer gauze layers partly saturated by the secretion. 
After the strips have been removed, the traumatic cavity should be free 
from pus. If the cavity as well as the lateral surface of the concha and 
the parotid region are covered with secretion, it is a sign that the band- 
age has remained too long in place and should in future be renewed more 
frequently. The largest quantity of secretion is discharged in the third 
week after the operation, and at about that period it will nearly always 
be necessary to renew the bandage daily. 

In cases of anaemia, diabetes, scrofulosis, or tuberculosis the quan- 
tity of secretion is sometimes exceedingly large and may require a change 
of bandage several times in a day. 

An unpleasant smell of the secretion is an indication of carious or 
necrotic particles of bone having remained behind ; sometimes it is a sign 
of an insufficient operation. Fetid secretion may sometimes be caused by 
particles of bone which have been chiselled off and retained in the cavity. 
If the tendon of the sternocleidomastoid muscle has not been properly 
removed when exposing the mastoid process, it may happen that particles 
of bone remain attached to the tendons, become necrotic, and lead to fetid 
secretion. After they have been removed or become detached spontane- 
ously, the fetid character of the secretion will rapidly lose itself. 

If the trauma runs a normal course, no exposed bone will be visible 
at the beginning of the fourth week. The cavity is completely invested 
with granulations, and a bluish-gray edge indicates the growing epi- 
thelium. 1 At this stage the rapid covering of the granulating traumatic 
surface with epidermal epithelium must be facilitated by treatment. Care 
should be taken to prevent uneven growth of the granulations. Such a 
contingency is nearly always caused by stagnation of the secretion, and 
the patient should therefore be instructed to renew the gauze strips him- 
self several times daily, and to remove the secretion mornings and evenings 
by instilling into the ear a few drops of peroxide of hydrogen. 

'In cases where the healing takes place without reaction, transplantation of the epidermis 
may be resorted to according to Politzer's method. 



208 THE DISEASES OF CHILDREN 

The growth of the epidermis is aided by insertion of cotton plugs 
saturated with alcohol. Where alcohol does not cause pain, hyperemia, 
or acute increase of the secretion, patients may instil the alcohol them- 
selves. For this purpose either a mixture of perhydrol and alcohol may 
be used, or perhydrol may be instilled in the morning and alcohol in 
the evening. 

For tamponading the traumatic cavity I use sterile gauze bandages 
12 feet long and 1 inch wide. The strip in the external meatus may be 
renewed by the patient himself as often as necessary, observing the 
greatest cleanliness. 

Under this treatment the epithelium may grow completely in 6-8 
weeks, but deviations from this ideal course are of such frequent occur- 
rence that they should be specially discussed. 

If cicatrization of the tympanic tubal end does not take place, and 
there is no suppurative secretion in the region of the tube, membranous 
occlusion of the antero-inferior part of the tympanic cavity may be 
expected. In these cases I insert the gauze strip merely toward the 
antrum, — i.e., into the back part of the tympanic cavity, — so that the 
spontaneous epithelial proliferation in the anterior part of the cavity 
may not be disturbed. 

If, on the other hand, there should be an accumulation of suppura- 
tive secretion in the tubal region, the antero-inferior part of the cavity 
must be kept permeable by careful tamponade, and the formation of a 
septum be prevented. The tampons are renewed once a day, except 
when the secretion is very considerable, when they should be renewed 
2-4 times daily. Cauterization with absolute alcohol, chromic acid, and 
insertion of scarlet red (Stein) once a week renders good service. As 
the epithelium grows, I assist the process by applying sunlight baths in 
summer, at other seasons lamplight; in office practice I insert small, 
cold electric lamps into the cavity, where they are allowed to remain for 
5 minutes. In very obstinate cases, where obliteration of the tubal 
ostium will not take place, I apply curettage to the tympanic tubal end 
under local injection anaesthesia. Development of a septum would be 
dangerous in these cases, as the secretion would stagnate behind the 
septum and, after an apparent cure, break out afresh. Later, insertion 
of 5 per cent, airol- vaseline or 5-10 per cent, cycloform ointment (for 
traumatic pain) is often beneficial. 

The radical operation may also result in a cure with formation of a 
membrane which is nearly always situated on the level of the former 
remnant of the tympanic membrane and which evidently has its start- 
ing-point at the remnants of the inferior margin of the tympanic mem- 
brane. In many cases this membrane is inserted along the facial re- 
gion; in others it runs to the backward margin of the traumatic cavity, 



AFFECTIONS OF THE MIDDLE EAR 209 

closing not only the tympanic cavity, but laterally the antrum region 
as well. The thickness of the membrane usually corresponds with the 
thickness of the tympanic membrane, but the fibrous layers show no 
regular arrangement. The membrane itself is perfectly smooth and 
covered at its lateral surface with epidermal epithelium, which has 
sometimes a metallic lustre. The middle-air spaces which are closed 
through the membrane contain air, and the ventilation occurs as in nor- 
mal conditions and by way of the tube in the act of swallowing. 

In some cases the formation of the epithelium and cicatricial oc- 
clusion of the tube may proceed without difficulty, but the granula- 
tions themselves remain thick and massy and are finally completely 
changed into connective tissue. This kind of wound, when healed, 
presents the otoscopic picture of a small hollow ball. The characteristic 
contour of the internal wall of the tympanic cavity is completely cov- 
ered by the thick connective-tissue layer. 

According to the way a radical operation heals, the cases may be 
divided into the following four groups : 

(1) Cases with formation of epithelium, perfect preservation of 
the osseous cavity, and obliteration of the tympanic tubal opening. 

(2) Cases with a membranous tubal septum. 

(3) Cases with a membranous occlusion of the middle-ear spaces 
and permeable tube. 

(4) Cases with connective-tissue atresia of the middle ear. 

All these results are practically of equal value and permanent, 
provided the patient's condition of nutrition is favorable. 

The membranous occlusion of the middle-ear spaces has the ad- 
vantage of completely protecting the latter against injury in a normal 
and anatomical manner from without. There is, however, the possi- 
bility of the patient contracting a typical acute inflammation of the 
middle ear if an acute infection of the nasopharyngeal space should set 
in, and especially if chronic suppurative conditions should create a 
predisposition for that affection. 

The physiological evacuation of the secretion of the auditory glands 
is usually completely arrested, owing to the external canal having en- 
tirely lost its tubal form and curvature through the plastic operation, 
so that one must be prepared for accumulation of cerumen in the op- 
erative cavity after every radical operation. If the middle wall of the 
tympanic cavity is exposed, pressure of these masses upon the wall of 
the labyrinth will cause headache and a sensation of fulness and heavi- 
ness in the ear, sometimes with objective signs of irritation of the laby- 
rinth (spontaneous nystagmus, vertigo). 

In membranous occlusion of the middle ear this danger does not 
exist, and in this respect the result is preferable. 

VI— 14 



210 THE DISEASES OF CHILDREN 

It is a matter of importance that the postoperative hearing acuity 
is the same in all four methods of healing. 

The epidermal epithelium investing the operative cavity is rapidly 
renewed during the first few months following operation, as scabs and 
crusts will be formed. If these are allowed to remain in the ear, macera- 
tion of the epithelial layer underneath and circumscribed ulceration 
may take place. In order to prevent this, patients are instructed to 
wear short sterile gauze strips after the wound has healed, and to renew 
the same daily. With their removal, the loose crusts are likewise re- 
moved. Besides, during the first year after operation the patient should 
attend at the physician's office one or twice a month and have the epi- 
dermis removed with the forceps should the same have been loosened, 
so that the cavity may always be covered with smooth, gray, glistening 
epidermis. 

The complete resection of the mastoid process means a rather con- 
siderable loss, and if it has been necessary to keep the retro-auricular 
wound open for a long time, it will be impossible to prevent the persis- 
tence of a retro-auricular aperture for some time, which is separated by 
an epithelial margin. Such an aperture may be closed by a direct suture 
up to 2-4 weeks after the operation. Later, however, the suture would 
cut through, and the aperture would reappear. All the methods for 
closing the retro-auricular gap are intended to provide a double layer of 
skin, one epidermal surface being turned against the operative cavity 
and the other toward the outside. 

Von Mosetig forms the lower flap from the region immediately be- 
low the mastoid process and closes the incision by sutures. Therefore, a 
new scar reaching to the neck is added to the operative scar, so that from 
a cosmetic point of view this method is not to be recommended. The 
disadvantage of Passow's method consists in both sutures being imme- 
diately above one another, so that they will easily cut through, like a 
simple suture. The method employed by myself has the great advant- 
age of the two sutures not lying immediately above one another, so that 
each of them is supported by the skin flap above and below. 

8. Attico-antrotomy 

In cases of chronic suppuration of the attic and antrum with well- 
preserved hearing acuity, the typical radical operation may be replaced by 
the much less severe attico-antrotomy. In this procedure the antrum is 
exposed from the mastoid process as in antrotomy . The lateral attic 
wall is removed until the junction of the malleus and incus becomes 
visible. The frame and the pars tensa of the tympanic membrane are 
preserved. After the performance of attico-antrotomy, Koerner's plastic 
operation of the auditory duct is done and the tongue-shaped flap pushed 



AFFECTIONS OF THE MIDDLE EAR 211 

toward the posterior wall of the antrum. The retro-auricular wound is 
closed down to the lower angle, a thin drainage strip being conducted 
through the latter outward. The after-treatment does not materially 
differ from that of the radical operation. Healing takes place by cover- 
ing the antrum and attic with epidermal epithelium. Both the attic 
and the antrum will now remain permanently open toward the auditory 
canal, a new membrane being formed only in exceptional cases. 

The treatment, until complete healing occurs, will occupy from six 
to ten weeks. 

Similar methods of operation have been proposed by Bondy and Heath. 

OTOGENIC PARALYSIS OF THE FACIAL NERVE 

Otogenic paralysis of the facial nerve develops in the course of an 
affection of the ear and the etiology of which can be connected directly 
or indirectly with the latter. Usually the paralysis is peripheral, ven- 
tral otogenic paralysis of the facial occurring only through endocranial 
otogenic affections. The paralysis is either complete or incomplete 
(paresis) ; there are also to be distinguished paralysis which sets in sud- 
denly in the course of an auditory affection and one which runs a more 
chronic course. 

Paralysis may further be divided into inflammatory and traumatic 
forms. The chief affections which are comprised in the former are 
those occurring in the course of acute or chronic inflammations — mostly 
suppurative — of the middle ear, furthermore those occurring in sup- 
puration of the labyrinth and suppurative inflammation of the internal 
auditory duct (usually a part manifestation of purulent meningitis). 
Only very rarely is paralysis of the facial nerve an accompaniment of 
neuritis acustico-facialis. Lymphomatoses (leukaemia, pseudoleukemia, 
chloroma, lymphosarcoma) may likewise be complicated by otogenic 
paralysis of the facial nerve. 

Paralysis of the facial nerve occurring in the course of malignant 
tumors of the middle ear should be classed as inflammatory paralysis, 
owing to the suppuration of the middle ear with which it is usually 
associated. It may also occur in combination with acusticus tumor 
(especially in cases of glioma and angiosarcoma) by normal tissue being 
replaced by the tumor. 

In the traumatic cases paralysis of the facial nerve occurs as a 
consequence of a traumatic injury of the auricular region or of a fracture 
of the base of the skull running through the petrous bone. Finally, a 
traumatic paralysis of the facial nerve may be caused by an operative 
injury of the nerve itself or its osseous canal. 

Central paralysis of the facial nerve may occur in otitic abscesses 
of the temporal lobe. In cerebellar abscesses peculiar changes of the 



212 THE DISEASES OF CHILDREN 

facial nerve may occur if the abscess extends more or less centrally in the 
worm or if it exerts special pressure on the fossa rhomboidea or perforate 
into the fourth ventricle. 

Anatomy. — The facial nerve turns from the crus cerebri outward 
and downward into the internal auditory canal, then runs over the 
acusticus laterally outward. It leaves the internal auditory duct at the 
foramen spurium canalis facialis and forms an angle of about 80° (lateral 
knee) backward and downward. It proceeds from here in the shape of 
an arch between the lateral semicircular canal and the vestibular win- 
dow downward and backward, and leaves the petrous bone through the 
foramen stylomastoideum. In its course between the lateral knee and 
the vestibular window it crosses the nervus utriculo-ampullaris and the 
recessus utriculi. 

There are no regular peripheral connections between the facial and 
auditory nerves. The bundle designated as nervus intermedius is situ- 
ated in the internal auditory duct below the facial and on the vestibular 
nerve, sometimes running more closely to the former and sometimes to 
the latter, without, however, entering into any intimate connection 
with either, and fusing with the geniculate ganglion. The latter lies 
outside the internal auditory duct at the foramen spurium. In chil- 
dren under four years of age it lies more or less free under the dura; in 
older children and adults an osseous plate, belonging to the petrous 
bone, grows from behind over the ganglion. Only about two-thirds of 
the fibres of the facial nerve are interrupted in the geniculate ganglion; 
one-third turns posteriorly into the facial canal (canalis Fallopii) with- 
out suffering any interruption by the geniculate ganglion, but uniting 
at once with the fibrous part interrupted by the latter, and forming 
the round facial nerve bundle. 

Where the facial nerve leaves the crus cerebri it contains marrow. 
The zone which contains marrow and the one which does not are sharply 
separated from each other, either in a straight or slightly convex surface. 
Gliotic, central, fibrous parts, protruding into the peripheral nerve, are 
but seldom to be found. The fibres composing the facial nerve are 
considerably thicker than those of the auditory. The cells of the genic- 
ulate ganglion are much larger than those of the vestibular or of the 
cochlear nerves. In the higher class of mammals there is a continuous 
connection between the geniculate ganglion and the upper — sometimes 
also the lower — vestibular ganglion. In other animals there are some 
varieties of continuous connections between the geniculate ganglion 
and the trigeminal ganglion. Rare clinical observations, especially on 
rheumatic affections in the regions of the trigeminal, facial, and auditory 
nerves, seem to indicate that similar connections occur exceptionally in 
man, but in my extensive anatomical material it has never been observed. 



AFFECTIONS OF THE MIDDLE EAR 213 

In its peripheral course the facial nerve sends out the following 
branches : 

(1) Nervus petrosus superficialis major. This nerve represents an 
anastomosis between the second trigeminus branch (ganglion spheno- 
palatinum) and the facialis. It forms the white portion of the nervus 
Vidianus and runs through the semicanalis nervi Vidiani to the gang- 
lion sphenopalatinum; it supplies the latter with motor fibres for the 
levator veli palati and with sensory fibres for the nasal mucosa. By 
the same route sensory fibres are supplied by the trigeminal ganglion 
for the facial nerve. 

(2) The nervus stapedius branches off from the descending part 
of the facial canal and is the motor nerve of the stapedius muscle. 

(3) The chorda tympani branches off below the stapedius nerve 
from the facial and arrives through the canalis chordse to the tympanic 
cavity. It traverses the latter between the malleus and incus in an 
arch running forward and downward, and arrives through the fissura 
tympani squamosa between the two pterygoid muscles at the lingual 
nerve. The chorda contains secretory fibres at the bottom of the mouth 
as well as fibres for the perception of taste, the latter supplying the mid- 
dle third of the tongue. A small branch is sent out by the chorda to 
the submaxillary ganglion and disappears in the sheath of the lingual 
nerve. 

(4) The nervus auricularis posterior branches off below the stylo- 
mastoid foramen, and is the motor nerve for the posterior auricular 
muscle and the occipital muscle. At about the same level there is a 
branch for the stylohyoideus muscle and the posterior part of the di- 
gastric muscle. 

(5) The nervus anastomoticus runs with the glossopharyngeus to 
the dorsal surface of the base of the tongue. 

(6) The plexus parotideus is divided into 3 parts: the upper (rami 
temporales, rami zygomatici) runs over the zygomatic bridge to the 
temples and forehead, the anterior runs to the cheek, and the inferior 
crosses the lower loop of the masseter and runs along the submaxillary 
bone forward (nervus marginalis mandibulse). The ramus of the facial 
nerve which supplies the platysma likewise branches off from the in- 
ferior plexus. 

Pathological Anatomy.— The pathologico-anatomical picture of the 
peripheral otogenic paralysis of the facial nerve varies considerably. 
In most cases there are suppurative infiltrates along the nerve sheaths; 
besides there are inflammatory infiltrates in the latter and between the 
nerve bundles, especially in the area of the geniculate ganglion. In 
many cases the nerve is bathed in pus; in others the osseous facial canal 
is destroyed by a chronic ostitis of the middle ear or by trauma. After 



214 THE DISEASES OF CHILDREN 

destruction of the osseous wall, granulations or cholesteatomata may- 
advance into the nerve and thus cause paralysis. 

In paralysis due to hemorrhage there are extensive effusions of 
blood into the nerve itself, while extensive extravasations between the 
osseous canal and the nerve-sheaths do not impair the function of the 
facial nerve unless the blood penetrates into the nerve. 

Trauma may injure the osseous facial canal, pulling at the nerve to 
a greater or smaller extent, or even tearing it. 

In postoperative paralysis of the facial nerve there are extensive 
hemorrhages in the nerve itself, if the paralysis occurs immediately 
after the operation. The hemorrhages may also be secondary, due to 
the chisel, or there may be an operative injury of the osseous facial 
canal, of the nerve within, or it may be completely destroyed. In rare 
cases a postoperative paralysis may occur through splinters of the 
fractured facial canal being pressed against the nerve and leading to 
considerable compression of the same. Postoperative paralyses which 
gradually develop in from 3 to 6 days after the operation occur either by 
direct infection at the operation or indirect by acute neuritis of the facial. 

Paralyses of the facial nerve which occur in the course of uncom- 
plicated acute otitis are chiefly caused by congenital tearing of the osseous 
facial canal. Suppurative inflammatory infiltration of the middle-ear 
mucosa may be the immediate cause of an inflammatory paralysis of 
the nerve. 

If the paralysis is caused by changes of the internal auditory duct, 
the bundles of the facial nerve have been destroyed by pus or granula- 
tions (complicated suppuration of the labyrinth). They may also 
be destroyed by tumors of the angle of the pons cerebelli or by pressure 
atrophy. 

All forms of facial paralysis present the common anatomical picture 
of a more or less advanced varicose disintegration of the axis-cylinder 
and degeneration of the medullary sheaths. 

Anatomical Course. — The peripheral fibres of the facial nerve have 
a high power of regeneration. The restoration of the fibres is favorably 
influenced by the curative process of the suppurative inflammation of 
the middle ear and the nerve-sheaths. Paralysis of the facial nerve due 
to hemorrhages is cured by resorption of the blood coagula. The re- 
generation occurs promptly if the local conditions permit, but even in 
cases of long standing the chances are favorable if the fibres are given an 
opportunity to recover, either by removal of any existing obstacles or 
by anastomosis with healthy motor fibres. 

Clinical Symptoms and Clinical Course. — The most striking symp- 
tom of unilateral facial paralysis is the arrest of the mimic musculature 
on the affected side. Paralysis of the oral branch renders the angle of 



AFFECTIONS OF THE MIDDLE EAR 215 

the mouth immovable, the malar skin loses its normal tension, becomes 
flabby, and is either bulging outward or injected through the act of 
respiration. Paralysis of the frontal branch is followed by loss of the 
voluntary movements of the skin of the forehead. Paralysis of the 
sphincter of the lid causes rather considerable lagophthalmos, accom- 
panied at first by increased, later by decreased lachrymation. In some 
cases, especially in children, lachrymation is entirely arrested, and the 
bulbar surface becomes dry. The defective or totally suppressed ability 
to close the lid exposes the bulb to the possibility' of traumatic injury; 
during sleep there is danger of contracting keratitis from drying up of 
the corneal moisture. Iridocyclitis or panophthalmia may develop in 
rare cases. If paralysis has existed for a long time, exophthalmos may 
result. Congenital paralysis of the facial nerve, occurring in early 
infancy, leads to asymmetry of the skull, the affected side growing 
larger than the healthy one. 

Localization. — If all the branches of the parotid plexus are involved 
in a peripheral otogenic paralysis of the facial nerve, the seat of the 
lesion lies in the trunk of the nerves centrally from the parotid plexus. 

If the nerve has been injured above the branching off of the auriculo- 
temporal nerve and below the chorda, there is, aside from paralysis of 
the mimic musculature, loss of motility of the neck and head. If the 
chorda tympani is involved, there will be disturbances of taste in the 
tongue; besides, there is a sensation of burning of the tongue on the 
affected side in the first stages of the attack. When the chorda has 
been destroyed, the potassium test of the saliva will be negative. 
Paralysis of the stapedius nerve causes slight reduction of the hearing 
acuity and subjective noises. If the seat of the paralysis is in the 
internal auditory duct, there will be functional disturbances in the area 
of the superficial petrous nerve. Unilateral paralysis of the velum 
palati occurs only in rare cases. 

In central paralysis of the facial nerve there is never a complete uni- 
lateral paralysis of the peripheral area of the nerve; there is always 
partial paralysis, affecting either the upper or lower area of the facial 
nerve, these regions being separated by the zygomatico-oculo-nasal line. 

Complete unilateral paralysis of the facial nerve gives rise to many 
disturbances. Mastication and drinking are difficult, as the food tends 
to escape toward the affected side, and at first patients are unable to 
prevent liquids from running out of the affected side of the mouth or 
solid food from protruding. After a while, however, they acquire a 
special knack enabling them to eat; with the aid of their fingers they 
manage to push solid food toward the healthy side, while liquids may be 
controlled by inclining the head toward that side. Whistling and suck- 
ing are impossible at first. In facial paralysis occurring in the course 



216 THE DISEASES OF CHILDREN 

of chronic middle-ear suppuration, the chorda and stapedius symptoms 
are of rare clinical occurrence. Paralysis of the frontal branch does not 
give rise to serious complaints. 

Unlike rheumatic paralysis, inflammatory otogenic paralysis of the 
facial nerve occurs but rarely as an apoplectiform affection. As a rule, 
the otitic paralysis sets in with slight disturbances in the region of the 
facial nerve (involuntary twitching, periodical lesions of the oral and 
ocular branches) , and it is only after some days or weeks that the affec- 
tion reaches its full extent. 

Diagnosis. — In the majority of cases the otogenic character of 
facial paralysis can be easily recognized from the history. This is es- 
pecially true of those cases which develop in the course of an acute or 
chronic suppuration of the middle ear. Where, however, this affection 
is not present and the tympanic membrane is intact, the differential 
diagnosis from rheumatic paralysis may cause difficulties. The guiding 
points lie in the history and the knowledge on the part of the patient 
whether the paralysis has slowly developed to its full extent in the course 
of several days or whether it was from the first of an apoplectiform 
nature. In the former case it points to otogenic, in the latter to rheu- 
matic paralysis. 

Central paralysis attacks either the upper or lower fractures of the 
facial nerve, so that there is never complete unilateral paralysis. Fur- 
thermore, in every form of peripheral paralysis of the facial nerve the 
electric excitability of the peripheral nerve is pathologically changed; in 
central paralysis it is normal. 

Prognosis. — The extent of the paralysis is of no particular conse- 
quence for the prognosis. Generally speaking, incomplete paralysis 
may be said to have a better chance than a complete one, but often 
enough there are exceptions. Of great importance is the rate at which 
the affection has developed. Thus, postoperative paralysis, which is 
complete from the first, is prognostically unfavorable, while cases which 
have gradually developed (not traumatic) are the more favorable the 
longer it has taken for the affection to develop. 

In peripheral paralysis a more accurate prognosis can be made by 
an electrical examination. Patients with faradic excitability have a 
chance of rapid and complete cure (three to six weeks). This holds 
good for all acute and most chronic cases of paralysis of the facial nerve. 
Chronic cases which can not be cured in spite of preserved faradic excit- 
ability are very rare. Paralysis with destroyed faradic excitability are 
to be regarded as serious cases, regardless of whether the paralysis is 
complete or incomplete. 

However, these cases have still a chance of recovery if the reaction 
of degeneration can be produced and the galvanic excitability increases 



AFFECTIONS OF THE MIDDLE EAR 217 

during two or three observations. In that case the reaction of degener- 
ation can be produced with a constantly decreasing current; finally it 
disappears altogether and the normal galvanic and later the faradic 
excitability will be restored. 

Cases in which the galvanic excitability of the nerve is still pre- 
served also give a favorable prognosis, as after a short time the faradic 
excitability is usually restored. 

The prognosis is unfavorable if the reaction of degeneration is 
combined with gradually diminishing excitability of the muscle; in these 
cases the production of the reaction of degeneration requires a constantly 
increasing strength of current. 

Similarly the prognosis is unfavorable in all cases in which the 
reaction of degeneration exists in mere traces, and the galvanic excita- 
bility is destroyed with the exception of rudimentary remnants, especially 
at the angle- of the mouth and the eyelid. 

Course. — It is difficult to form an opinion as to the length of time 
required to effect a complete cure. In prognostically favorable cases of 
serious paralysis with destroyed faradic excitability the time required 
is from three to six months, but the motor function on the affected side 
may nevertheless remain weak for a considerable time, perhaps for 
years; in other cases the function of the nerve will never be completely 
restored. 

But even in cases in which no complete cure is possible a certain 
balance is restored, and with the aid of the trigeminus of the affected 
side or the facial and trigeminal nerves of the healthy side, and by 
practice, the most serious disturbances in the ingestion of food and 
speech will disappear. 

The cases which defy cure may be divided into two groups, — 
paralysis which persists in the flabby form, which occasionally leads to 
atrophy of the facial skin and of the malar adipose tissue; and paralysis 
in which there is gradual development of muscular contracture. Mod- 
erate contractures are favorable for the cosmetic effect. The normal 
facial contour is restored and the closure of the lid improves. But if 
the contractures continue to increase, the disturbance will assume 
considerable proportions, the angle of the mouth will be distorted and 
there will be passive permanent closure of the lid. 

Treatment. — Should facial paralysis be caused by chronic suppura- 
tion of the middle ear, immediate radical operation is indicated. In 
the majority of these cases facial paralysis is a very bad sign, showing 
as it does that, owing to the spreading of suppurative ostitis or a gradu- 
ally growing or acute suppurative cholesteatoma, the labyrinth and 
endocranium are likewise endangered. It is necessary, therefore, in 
each case of facial paralysis occurring in the course of chronic suppura- 



218 THE DISEASES OF CHILDREN 

tion of the middle ear, to examine the patient very carefully for labyrin- 
thitis or an endocranial otitic affection. 

Light cases of facial paralysis (with preserved faradic excitability), 
occurring in the course of acute middle-ear suppuration, admit of con- 
servative treatment of the latter, provided it runs a perfectly normal 
course, which means normal temperature, no pain, no mastoid symp- 
toms, no descent of the posterosuperior wall of the auditory duct, and 
gradual decrease of the suppuration with increasing hearing acuity. In 
all other cases immediate antrotomy is indicated. 

If the paralysis is postoperative, the bandage should be immediately 
and completely removed, so that a search for bone splinters may be 
instituted and a reliable drainage for the middle-ear spaces provided 
for. The retro-auricular wound should be kept open. 

Where the paralysis is a part-manifestation of suppuration of the 
labyrinth, the latter should be resected, and, should there be simul- 
taneous signs of suppurative meningitis, the internal auditory duct 
should be exposed. 

Favorable results have been reported of the operation of opening 
the facial canal and exposing the facial nerve in the middle ear in cases 
where postoperative paralysis has been present for a long time. After 
traumatic paralysis due to injury or complete severing of the nerve and 
its osseous canal, the operation of broadly opening the facial canal may 
likewise be attended with success, provided it is possible to remove all 
obstacles which have prevented reunion of the divided nerve-ends, or to 
chisel out an osseous groove serving as a kind of splint for the severed 
nerve-ends. 

As to the rest of the conservative and surgical treatment of an 
otogenic paralysis of the facial nerve, the same therapeutic rules hold 
good which are followed in facial paralysis generally. In light cases 
faradic treatment, applied for 5-10 minutes every day, is sufficient. 
The highest electric energy is applied which can be borne by the patient 
without discomfort. 

Should the faradic excitability be destroyed, the galvanic current 
is resorted to. With excitability preserved from the nerve, the best 
plan is to apply one electrode to the trunk of the nerve below the lob- 
ulus, and the other to an indifferent place, such as the hand, chest, or 
neck. Besides, galvanization of the paralzyed muscle itself should be 
applied. 

With the excitability from the nerve destroyed, the treatment 
must be confined to the paralyzed muscles. 

The electric treatment is considerably aided by light massage of 
the facial muscles and mimic exercises carried out by the patient before 
the looking-glass. Hot-air treatment, perspiration, and laxatives are 



AFFECTIONS OF THE MIDDLE EAR 219 

only of value in otogenic paralysis of the facial nerve if the affection has 
developed in the course of simple acute otitis media. 

Old cases of otogenic facial paralysis belong to the domain of the 
surgeon, who will endeavor either to cure the paralysis by anastomosing 
the facial nerve with the accessory or the hypoglossus nerves; or he must 
content himself with overcoming the most disfiguring or objectionable 
disturbances by plastic operation. 

In anastomosis the following methods are to be distinguished : 

(1) Anastomosis between the facial nerve and the motor branch 
of the accessory nerve. A skin incision 4-5 mm. long and slightly curved 
backward runs from the insertion of the concha to the posterior edge of 
the sternocleidomastoid muscle. The soft parts are pushed aside with 
a blunt instrument until the pedicular process can be felt. Immediately 
behind the latter there is the trunk of the facial nerve, enclosed in a 
thick sheath. This is dissected free and pulled forward with a small 
forceps. In doing so, it is useful to roll up the nerve-trunk upon the 
forceps, so that the nerve may be intersected as high as possible in the 
facial canal. The end of the facial nerve is caught by a silk suture and 
cut off in an oblique direction. Now the accessory nerve is exposed and 
followed upward to the bundle intended for the deltoid muscle. At 
this place an end-to-end anastomosis is usually done by cutting the 
deltoid branch of the accessory nerve in an oblique direction and unit- 
ing the cut central end with the peripheral end of the facial nerve by 
two interrupted silk sutures. The use of silk sutures in nerve anasto- 
moses has been recommended because an inflammatory reaction is 
advantageous for the rapid union of the anastomosed nerves. 

If lateral anastomosis is preferred, the same motor branch of the 
accessory nerve is nipped with the scissors and incised. The neuri- 
lemma being thus removed and a number of severed nerve-fibres exposed, 
the end of the facial nerve is implanted and fastened with interrupted 
sutures. A thin drainage strip (isoform or iodoform wick) is inserted 
from the lower traumatic angle to the anastomosis, and the skin wound 
is closed by Michel's clamps. 

(2) Anastomosis between the facial nerve and the hypoglossus 
nerve. The skin incision runs from the lower insertion of the concha 
straight to the hyoid bone for about 4 cm. The trunk of the facial 
nerve is dissected free as in anastomosis with the spinal accessory nerve. 
The hypoglossus nerve is next searched for in the trigonum digastricum or 
before the digastricus, after which a lateral anastomosis can be done by 
a superficial incision of the hypoglossus, or an end-to-end anastomosis by 
intersecting the hypoglossus. A drain is conducted through the anterior 
traumatic angle to the anastomosis, and the skin wound closed by 
Michel's clamps. 



220 THE DISEASES OF CHILDREN 

Indications for anastomosis are in fresh cases of facial paralysis where 
the traumatic changes of the facial canal and nerve render conservative 
treatment absolutely hopeless, as for instance in compound fractures, 
in which not only the nerve has been severed, but part of it has been 
destroyed, and the osseous facial canal has undergone serious injury. 
Anastomosis is also indicated in inflammatory paralysis when part of 
the nerve and osseous canal has been completely destroyed by chronic 
suppuration of the middle ear or cholesteatoma. 

In cases where the continuity of the facial nerve has not been im- 
paired, anastomosis should not be considered until all conservative 
measures have been found unavailing. It is then important not to 
miss the proper time for surgical interference. In complete paralysis 
of the facial nerve, with destroyed faradic and diminishing galvanic 
excitability from the muscle and negative excitability from the nerve, 
anastomosis is usually indicated if after 6-12 months' conservative 
treatment there are no favorable changes in the excitability and no func- 
tional improvements. In cases that have been paralyzed for more than 
two years there is usually no more chance of benefiting the patient by 
anastomosis, because during that length of time the entire nerve is 
usually so degenerated that a nutritive union with a healthy motor 
nerve will be impossible. 

Postoperative Course. — Facial anastomosis being only resorted to 
in complete peripheral paralysis, resection of the paralyzed facial nerve 
will at first not give rise to external improvement. It has also been 
uniformly observed that small remnants of retained function in the 
regions of the eyelids and the angle of the mouth will not be impaired 
by central resection of the facial trunk. This fact goes to prove that 
these remnants of innervation are not referable to the paralyzed nerve; 
they are the result of vicarious function of ramuli of the motor trigemi- 
nus of the same side or of the facial nerve of the healthy side. 

Successful end-to-end anastomosis between the facial and accessory 
nerves leads almost always to paralysis of the shoulder on the oper- 
ated side; that between the facial and hypoglossus to unilateral paraly- 
sis of the tongue. These manifestations will often completely disappear 
in from eight to twelve months; in other cases they will permanently 
continue. In lateral anastomosis the region of the accessory and hypo- 
glossus may not be functionally disturbed; in most cases, however, 
paralysis will occur and disappear after four to twelve months. 

Successful treatment depends upon various circumstances. Thus, 
the degeneration of the facial nerve must not be excessive and, as has 
been shown by experimental studies, the remaining medullary sheaths 
must be of sufficient length and in fairly normal condition. 

The first symptom of improvement in favorable cases occurs in 



AFFECTIONS OF THE MIDDLE EAR 221 

from six to twelve months, shorter periods being rare. These cases 
require regular galvanic treatment, in the course of which the patient 
may report improvement in mastication and drinking, later in whistling, 
and finally in aspiration. 

A perfectly ideal success with restoration of the entire mimic mus- 
culature, however, is of rare occurrence. In the cured cases independent 
innervation of the facial nerve is impossible. The voluntary use of the 
mimic musculature is combined with movements of the shoulder in 
anastomosis between the facial and accessory nerves, or by movements 
of the tongue in anastomosis between the facial and hypoglossus nerves. 
Occasionally voluntary contractions of the shoulder and lingual muscles 
are accompanied by passive twitching in the region of the facial nerve. 
It is questionable whether these patients will ever reacquire the ability 
of innervating the facial singly. This would require regeneration and 
isolation of the cortical motor fields of the facial nerve, and it is assumed 
that this would more easily take place after anastomosis between the 
facial and hypoglossus nerves, because the cortical field of the latter 
closely approaches the lower cortical field of the former. On the other 
hand, the facial nerve is at a much greater distance from that of the 
accessory nerve, so that permanent associated movements of the shoulder 
have to be expected. 

Gersuny proposed a plastic method for the cure of flaccid paralysis 
where the soft parts of the cheeks and malar skin have been considerably 
stretched. He conducts a silk or silver wire suture from the zygomatic 
region to the angle of the mouth and back to near its starting-point, 
in order to raise the angle of the mouth by contractures. The suture 
ends are knotted over a small iodoform roll. The suture is allowed to 
remain in situ from four to six weeks, and the result is said to be favor- 
able in producing medium-grade contractures. 

In chronic flaccid paralysis or high-grade contractures in the region 
of the eyelid, a lid plastic operation is to be considered. For the details 
of the various methods, text-books on ophthalmology should be consulted. 
It has already been mentioned that high-grade muscular contractures 
represent the worst result of a permanent facial paralysis, and the best 
way to prevent their development is regular galvanization from the 
muscle for ten minutes once or twice weekly and continued, if necessary, 
for several years; and in addition massage, hot-air baths, and induce- 
ment of perspiration. 

Many patients learn to massage their face so well that the muscles 
retain their tone. Usually a pinching of muscles followed by a thorough 
rubbing upward toward the eye is sufficient to mantain some degree 
of action. 



X. AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 

I. EXOSTOSES OF THE LATERAL WALL AND OBLITERATION OF THE WINDOW 

OF THE LABYRINTH 

Exostoses are seldom observed at the lateral wall of the labyrinth. 
They occur occasionally in chronic suppuration of the middle ear at 
the corners of the fenestra?, at the auricular ossicles, at the promontory, 
or at the eminence of the lateral semicircular canal. Leidler has called 
attention to diffuse new-formation of bone at the walls of the tympanic 
cavity in cases of acquired atresia of the auditory duct. 

According to past experience it is not impossible that even a frac- 
ture or pathologic fistula of the labyrinth may heal. Congenital exos- 
tosis at the capsule of the labyrinth is exceedingly rare; it appears only 
as part manifestation of a pronounced general deformity of the body 
with severe malformation of the ear (anencephaly, synotia). 

Obliteration of the windows of the labyrinth may be due to connec- 
tive tissue or bone formation. Obliteration by connective tissue is the 
result of catarrhal adhesive processes of the middle ear or of a middle- 
ear suppuration. Both window corners are replete with cicatricial 
tissue, while coarse connective-tissue layers extend to the stapes plate 
and the membrane of the cochlear window. Window corners filled with 
connective and fatty tissue have been observed in cretins. 

The mucous tissue which is normally found in the tympanic cavity 
of the new-born will persist longer than usual in rhachitic children and 
completely fill up the window corners. 

Ulceration of the mucous membrane and superficial osseous erosions 
at the middle wall of the tympanic cavity, and osseous atresia of both 
labyrinth windows, occurring in chronic suppuration of the middle ear, 
seldom can be cured. The corner of the cochlear window is completely 
filled with bone, and the entire stapes may be replaced by osseous pro- 
liferation from the vestibular window. 

Obliteration of the labyrinth windows (stapes ankylosis and oc- 
clusion of the cochlear window) may also occur in otosclerosis if the 
pathological bony proliferation of the lateral wall of the labyrinth has 
involved the labyrinth windows. 

Exostoses of the lateral wall of the labyrinth, without obliteration 
of the cochlear windows, do not cause any particular cranial symptoms. 
Considerable reduction or complete destruction of the hearing acuity 
of the affected ear in the presence of exostosis is due to the fact that 
those affections in which exostoses occur lead of themselves to consider- 

222 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 223 

able injury or destruction of the membranous labyrinth, of the nerve- 
end places, and of the eighth nerve. 

Diagnosis. — In exposed middle-ear spaces — i.e., after destruction of 
the attic or antrum wall — exostoses may sometimes be otoscopically 
demonstrated; generally, however, they are accidentally met with on 
the occasion of a radical operation. Obliteration of the labyrinth win- 
dows is indicated by the negative result of Gelle's test. 

Treatment. — There can be no question of any treatment except in 
obliteration of the window corners by connective tissue in the presence 
of chronic adhesive processes. Politzer recommends resection of the 
ligament and exposure of the window corners. Wherever the mem- 
branous cochlea and Corti's organ have been preserved, or at least not 
materially injured, it is possible to obtain considerable and permanent 
improvement of the hearing acuity by. this operation. The indication 
for it must be given by the test with the c4 tuning fork, establishing 
the upper sound limit. If the perception of the c4 fork for air-conduc- 
tion is only slightly shortened (2-10 seconds), resection of the cicatrices 
will surely lead to a favorable result; if, however, the perception for c4 is 
considerably reduced and the high-sound limit quantitatively impaired, 
endotympanic surgery offers no chances of success. 

II. ACUTE, SUPPURATIVE PARALABYRINTHITIS 

Suppurative paralabyrinthitis is characterized by the suppurative 
softening and absorption of the bone in the area extending from the 
osseous capsule nearly to the labyrinth spaces. It may become more 
extensive in the angle of the semicircular canal. The superficial bone 
erosions of the middle wall of the tympanic cavity likewise belong to 
the group of affections designated as paralabyrinthitis. 

Acute suppurative labyrinthitis usually presents no symptoms 
either at the beginning or in its course. The diagnosis can clinically 
be made in rare cases from the expulsion of the smallest sequestra from 
the paralabyrinth, or from the occasional recognition at a mastoid opera- 
tion. The affection is relatively frequent in childhood and is observed 
oftener in the case of acute than of chronic middle-ear suppuration. 

In cases of acute middle-ear suppuration the cause of paralabyrin- 
thitis is usually a mastoid suppuration with manifestations of retention. 
The danger of paralabyrinthitis is especially great in early age as long- 
as the petrous bone possesses large diploic spaces filled with marrow, or 
pneumatic spaces. In the chronic cases paralabyrinthitis is nearly 
always caused by middle-ear suppuration, which may be either tuber- 
culous or complicated by cholesteatoma. 

The treatment consists in the radical operation and surgical removal 
of the affected bone with the sharp spoon; operative injury of the laby- 
rinth must, of course, be avoided. 



224 THE DISEASES OF CHILDREN 

The prognosis is not unfavorable in acute uncomplicated cases, 
but it is advisable to keep the retro-auricular aperture open as long as 
possible in order to prevent the possibility of a weak superficial healing, 
recesses, or trabecular. 

In the chronic cases there is danger of postoperative serous laby- 
rinthitis. If paralabyrinthitis is caused by a tuberculous middle-ear 
suppuration, there is a possibility of an acute tuberculous suppuration 
of the labyrinth and the danger of tuberculous meningitis. 

III. FISTULA OF THE LABYRINTH 

A fistula of the labyrinth is an abnormal communication of the 
labyrinth spaces with neighboring spaces caused by a pathological 
process. From a topographical point of view, these fistulse have, there- 
fore, to be divided into intra- and extracranial, and among the latter 
the tympanic variety occupies a distinct place. Intracranial fistulse of 
the labyrinth lead into the middle or posterior cranial fossa, the extra- 
cranial ones into the middle-ear spaces (tympanic cavity and antrum) 
or into the fossa jugularis. Fistula? of the endolabyrinth may be classed 
as a special group, but they are usually congenital defects. They occur 
from congenital arrest of development, preventing the formation of 
the normal bony septa in the embryonal labyrinth. In the most pro- 
nounced cases the labyrinth is a single space with hardly any divisions, 
while in cases of less pronounced malformation there are abnormal con- 
nections between the spaces of the labyrinth. Even the septum between 
the latter and the posterior semicircular canal may be absent, which is 
especially observed in congenital deafness and congenital absence of 
the scala of the cochlea. 

Acquired fistulas may occur either through preformed or patholog- 
ically developed routes. The preformed routes are the fenestra vestibuli, 
fenestra cochleae, aquseductus vestibuli, aquseductus cochlea?, and in- 
ternal auditory canal. In these cases a fistula occurs by the destruction 
of the corresponding bones or soft parts through a pathological process. 

Fistula? occurring over routes not anatomically preformed may of 
course start from any point in the labyrinth, but also from any region 
of the endocranium or the ear. There are, however, certain places of 
predilection in the labyrinth, — namely, where there is only a relatively 
thin bone protection against the endocranium, the middle-ear spaces, 
or the fossa jugularis. Such places are the following: (1) promontory; 
(2) the lateral crus of the external semicircular canal; (3) the vortex of 
the upper semicircular canal or, in children up to the fourth year, the 
entire upper semicircular canal; (4) the sinus end of the sagittal semi- 
circular canal; (5) in infancy, the commissure of the semicircular canal. 

It may be mentioned that, even in normal conditions, the dimen- 
sions of the bony layer at the places mentioned are very variable, and 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 225 

that infantile affections of the osseous system, notably rhachitis, may 
be the cause of these superficially situated parts retaining their original 
topography far beyond the infantile age. 

Fistula? of the labyrinth are divided according to their origin into 
excentric and concentric varieties. An excentric fistula is one which 
originates by a suppurative process within the labyrinth and breaks 
through the capsule and the petrous bone. The concentric fistula occurs 
from an affection spreading from the surrounding parts to the capsule 
of the labyrinth, leading to a fistulous perforation of the labyrinth from 
without. It is clear, therefore, that excentric fistula? show the result of 
a suppuration in the labyrinth, and the concentric ones show the begin- 
ning of a suppuration in the labyrinth. 

The endocranial fistula? are subdivided into intradural and extra- 
dural ones; the extracranial fistula? into subperiosteal and intravenous 
(perforating into the bulbus of the vena jugularis or into the sinus sig- 
moideus) . 

Among the tympanic fistula? of the labyrinth we distinguish between 
submucous and perforating. The former occur through the fistulous open- 
ing being closed against the middle-ear spaces owing to the pathologically 
thickened tympanic mucosa, and the latter through the fistula discharg- 
ing its contents against the middle-ear spaces. 

Furthermore, fistula? may have different relations to the labyrinth 
spaces, which give rise to the following distinctions: paralymphatic, 
perilymphatic, and endolymphatic. The paralymphatic fistula? occur 
through the destruction of the osseous capsule, the perilymphatic con- 
nective-tissue capsule remaining intact; in the perilymphatic fistula? a 
communication has been established between the perilymphatic spaces 
and the fistular canal, and the endolymphatic fistula? communicate with 
the endolymphatic spaces. 

A study of the various groups with regard to the last-mentioned 
point will result in the following: The excentric fistula? are absolutely 
endo- and perilymphatic. The excentric endocranial fistula? are intra- 
dural if they have developed by way of the cochlear aqueduct or of the 
internal auditory canal; they are extradural if developed via (1) the 
vestibular aqueduct; (2) the frontal semicircular canal; (3) the sagittal 
semicircular canal ; (4) the commissure of the semicircular canal ; (5) the 
ductus and sulcus endolymphaticus. These fistula? can only become 
intradural after destruction and fistulous perforation of the dura. 

As to the concentrically originated fistula?, it can be stated that, if 
the affection is slight or takes a very slow course, the changes will be 
arrested at the external surface of the perilymphatic capsule of the 
labyrinth. The reason for this may be either that after destruction of 
the bene the pathological process has no tendency to spread any further, 

VI— 15 



226 THE DISEASES OF CHILDREN 

or that during the long period required for destroying the osseous wall 
reactive changes have taken place in the labyrinth spaces by new-forma- 
tion of connective tissue or bone, which prevent the fistula from con- 
tinuing its course into the peri- or endolymphatic spaces. 

Submucous tympanic fistulse are especially found after excentric 
destruction of the cochlear window. The corner of the latter has usually 
been closed for some time against the tympanic cavity by connective- 
tissue layers. The fistular contents (pus) now exude into the corner of 
the round window, but cannot reach the free tympanic cavity. 

Symptoms and Course. — The formation of labyrinth fistulse usually 
occurs under violent irritative manifestations of the labyrinth. The 
permeability of the fistula in the area of the static labyrinth is indicated 
by a violent attack of labyrinthine vertigo. In excentric fistulse these 
attacks of vertigo have already been preceded by a few others of minor 
intensity, while in concentric fistulse the patient never had an attack 
before, but the violent attack is followed later by a series of long- 
lasting or repeated lighter attacks. The auditory acuity undergoes 
sudden deterioration, and in some cases instant deafness will set in. 
The permeability of excentric fistulse, however, may occur without 
giving rise to any symptoms if the membranous labyrinth had already 
been destroyed for some time previous to the development of the fistula. 
For labyrinth fistulse in suppurative paralabyrinthitis, see p. 271. 

The formation of a labyrinth fistula may be followed by diffusely 
spreading destruction of the osseous capsule which may cause the destruc- 
tion of the lateral wall of the labyrinth ; in isolated cases the entire laby- 
rinth may be sequestered. This end result occurs especially in excentric 
fistulse which are only part manifestations of a chronic, diffuse, compli- 
cated suppuration of the labyrinth. In concentric fistulse the chances 
of a cure are favorable, provided a middle-ear operation has been done 
in time, consisting in antrotomy for acute or subacute, and in the radical 
operation for the chronic cases. Closing of the fistula will take place 
by connective-tissue scars or new bone formation. 

The diagnosis is principally based upon the history concerning the 
first attack of vertigo or the clinical observation of such an attack. In 
typical cases the occurrence of vertigo is contemporaneous with the 
permeability of the fistula; concentrical fistulse especially are accom- 
panied at the time of their breaking through by typical and sometimes 
stormy symptoms of vertigo and equilibrial disturbances of the laby- 
rinth. Acute diminution of the auditory acuity or sudden deafness is 
not a rare occurrence. In fresh cases the static labyrinth usually shows 
pathologically increased (prolonged) reflex excitability (Stage II of 
inflammatory irritation, see p. 269). For clinical fistular symptoms, 
see p. 93. 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 227 

Treatment. — Fistulso occurring in acute suppurative paralabyrin- 
thitis will heal spontaneously after antrotomy or the radical operation 
has been performed. If the fistula is due to acute or subacute middle- 
ear suppuration, antrotomy is indicated; if due to chronic middle-ear 
suppuration, the radical operation should be done. After the opera- 
tion the irritative phenomena rapidly disappear, and, as a rule, no more 
vertigo will occur as soon as the retention of pus in the middle ear and 
the consequent increase of pressure upon the fistula have been removed. 
In cases where a concentric fistula has been caused by an acute or sub- 
acute middle-ear suppuration, the hearing acuity will be improved or 
restored to normal. The hearing acuity in cured chronic cases is rarely 
satisfactory ; in fact, deafness may gradually set in a long time after the 
fistula has been closed. This contingency is attributable to degenera- 
tive atrophy of Corti's organ. 

IV. OTOSCLEROSIS 

The etiology of otosclerosis is not known. The suggestion of Haber- 
mann and others that it is a metaluetic or hereditary syphilitic affection 
has been refuted by Arzt, 0. Beck, and others. 

As it is just in hereditary syphilis that Wassermann's reaction is 
very reliable, the test in otosclerosis should be positive in a large number 
of cases. Such, however, is not the case by any means; on the contrary, 
it has long ago been demonstrated that otosclerosis is the type of heredi- 
tary affections of the ear. 

Genealogical statistics have proved the continuous heredity of oto- 
sclerosis, even in the branch lines of affected individuals, and sometimes 
omitting an entire generation. 

Otosclerosis may also be a part manifestation of hereditary degener- 
ative changes of the central nervous system. Thus, there are forms of 
psychic affections and otosclerosis in descendants of the same family. 
In other cases a tendency to heredity is associated with otosclerosis. 
Hammerschlag is right, therefore, in describing the affection as one of 
hereditary difficulty of hearing. 

Anatomy. — Politzer recognized otosclerosis as an affection of the 
osseous capsule of the labyrinth. When examining the petrous bone in 
otosclerosis, there are found pathological foci of bones which, in the 
shape of sharply demarcated tumors, often replace the normal bone of 
the capsule. Sometimes the pathologically changed bone is not clearly 
separated from the normal one, or both may gradually fuse into each 
other. The pathological foci are composed of bone that abounds in cells 
and lime. The histological examination shows that petrous bones which 
are normally already decalcified still contain lime in the pathologically 
changed portions. In the histological examination, the normal bone 



228 THE DISEASES OF CHILDREN 

stains bright red under application of haematoxylin-eosin, while the oto- 
sclerotic foci assume a reddish-blue or deep-blue color. As compared to 
the compacta of the normal petrous bone, the otosclerotic foci have very- 
large hollow spaces which are freely permeated by pathologically en- 
larged blood-vessels. There is a rather dense net-work of connective 
tissue spread out between the bone and the vessel walls. The favorite 
seat of these foci is the lateral walls of the labyrinth. As they become 
gradually enlarged, the osseous foci lead to gradual thickening of the 
lateral wall of the labyrinth, constriction and finally osseous obliteration 
of the window corners, and ankylosis of the stapes. 

In some cases the osseous foci protrude, tumor-like, into the laby- 
rinth spaces (vestibular cistern, scala tympani). They occur less often 
in the area of the semicircular canals, body of the cochlea, or near the 
internal auditory canal. The topographical relation of the pathological 
osseous foci to the surface of the labyrinth is of importance. It may be 
assumed that otosclerotic foci may exist without symptoms, as long as 
they have not reached the windows of the labyrinth and the inner sur- 
face of the capsule. Findings in congenitally deaf individuals and 
cretins justify the assumption that the otosclerotic osseous foci are 
chiefly of congenital origin, situated in infants and young children in 
the petrous bone itself, as are the cartilaginous interglobular spaces; 
thus, they reach at that time neither the inner nor outer surface of the 
capsule nor the windows of the labyrinth. It is not before the period of 
puberty that increased growth of the pathological osseous foci seems to 
occur. They now extend to the windows of the labyrinth and reach the 
labyrinth spaces or the dural lining of the internal auditory canal. This 
assumption is supported by the clinical fact that the first important 
clinical symptoms in a great number of cases of a pronounced hereditary 
character do not occur until the period of puberty. Both ears are mostly 
attacked, but not in the same measure nor at the same time. Restric- 
tion to one ear is a rare occurrence. 

According to their anatomical structure, the pathological osseous 
foci of the capsule have nothing to do in an anatomical sense with the 
ordinary sclerosis of the bones. The name of "otosclerosis" is, there- 
fore, not justified, as it only designates the clinical conception of the 
affection. Attempts have, therefore, been made to coin a correct ex- 
pression for the anatomical changes. Siebenmann's "spongiosis of the 
labyrinth capsule" must be rejected, as the pathological osseous foci 
are totally different from normal spongiosa of the bone. The hollow foci 
of spongiose bones are filled with medullary tissue; those in otosclerosis 
are filled with pathologically enlarged and new-formed blood-vessels. 
The expression "stapes ankylosis" describes only part of the cases cor- 
rectly, as in many cases no such ankylosis occurs and the bony changes 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 229 

are limited to other places of the capsule or to regions of the cochlear 
window. I believe I have found a correct term in "osteitis vasculosa." 
Indeed, the impression gained from the histological picture is that the 
otosclerotic foci are the result of a non-suppurative inflammation of the 
bones, which has led to the pathological enlargement of the blood-vessels, 
to increased cell-formation, and to increased lime deposits in the bone. 

The idea of otosclerotic foci being the end result of a periostitis of 
the capsule is only borne out by a few specimens in my collection, whereas 
in many cases of typical otosclerosis any periosteal changes cannot be seen. 

The anatomical changes of the capsule itself are sometimes associ- 
ated with changes of the tympanic and the membranous labyrinth. 
The changes of the tympanic cavity are characterized by diffuse thick- 
ening of the mucous membrane of the middle tympanic wall and by 
considerable osmosis, increased vascularization, and hyperemia of that 
mucosa. Serous osmosis of the mucosa of the middle ear may also lead 
to accumulation of a serous exudate in the tympanic cavity. As matter 
of fact, cases of otosclerosis have been observed which set in under the 
clinical manifestations of an exudative middle-ear catarrh. Such exu- 
dates, however, are not demonstrable in older cases. 

The changes of the internal ear consist in degenerative atrophy of 
the sensory epithelium and the eighth nerve. In some cases these destruc- 
tive changes involve the entire labyrinth; in others the vestibularis is 
spared. There is a great difference in the chronology of the capsular 
changes and those of the membranous labyrinth as compared to the 
auditory nerve. According to the clinical course, the rule will hold good 
in most cases that the degeneration of the sensory epithelium and audi- 
tory nerve develops secondarily upon advanced changes of the capsule. 
In other cases the changes of the capsule and membranous labyrinth 
appear to set in synchronously. Kalenda's investigations have shown 
that the symptoms furnished by the degeneration of the labyrinth may 
occur previous to the clinical symptoms of otosclerosis in cases which 
according to their later course or to the functional findings have to be 
diagnosed as otosclerosis. 

Symptoms. — The most striking early symptom of otosclerosis con- 
sists in subjective ear noises of different kinds, such as the roaring of 
water, buzzing, humming, whistling, pulsating knocks, etc. They are 
increased by rush of blood to the head following physical exertion, ex- 
citement, and all efforts which increase the blood-pressure. In many 
cases the subjective noises are so violent that they molest the patient 
more than his impaired hearing. In other cases again they are less 
obtrusive or completely absent. The degree to which hearing is impaired 
varies considerably and depends in the first place on the stage of the 
affection. It is intelligible that hearing should be less impaired in the 



230 THE DISEASES OF CHILDREN 

beginning than at later stages. Generally speaking, gradually increasing 
difficulty of hearing is characteristic for otosclerosis. In some cases the 
hearing acuity decreases rapidly, so that it requires but a few years for a 
high degree or total deafness to establish itself. In other cases the pro- 
gressive character of the affection is less pronounced, so that even after 
20 or 30 years the hearing ability is still considerable. Even temporary 
improvement in the hearing acuity has been observed in rare cases. 
Physical exhaustion, mental excitement, psychic impressions, disturb- 
ance of the general health, may considerably impair the hearing, al- 
though at first only temporarily. Affections of the nasopharyngeal 
tract likewise exert an influence upon the degree of hearing ability. 

If the static labyrinth is involved, there will be vertigo and equi- 
librial disturbances. The paroxysms of vertigo are usually not severe, 
and the equilibria! disturbances are restricted to the duration of the 
vertigo. A later symptom of otosclerosis consists in violent pains in the 
auricular region which are sometimes accompanied by reactive hyper- 
emia. There are also changes in the voice. When the hearing acuity is 
considerably reduced and the labyrinth is still intact, the patient per- 
ceives his own voice greatly intensified and even roaring. He endeavors 
to correct this by adapting a very much softer key. In considerable 
impairment of the auditory acuity, speech becomes drawling and the 
articulation indistinct. This is especially the case if hearing has already 
been impaired at juvenile age. 

A frequent symptom is paracusis Willisii, which consists in improved 
hearing amid great noise, such as carriage or railway riding or loud 
music. Politzer explains this by assuming mobilization of auricular 
ossicles, the articulations of which had become rigid and now become 
more capable of conducting sound. At the same time the equilibrium of 
the auditory-nerve termination is disturbed, which facilitates the per- 
ception of sound. According to Urbantschitsch, this phenomenon is 
due to increased excitability of the auditory nerve caused by the con- 
cussion. Occurrence of hyperesthesia in otosclerosis may be followed 
by grave general nervous manifestations. 

Froschels states that the sensation of titillation in the external 
auditory meatus is often reduced or absent. 

Course and Prognosis. — The course of otosclerosis is unfavorable, 
but the various cases differ considerably in regard to prognosis. In a 
general way it may be said that the prognosis is the less favorable the 
earlier in life the affection has set in. The most unfavorable cases are 
those in which the impairment of hearing dates back to childhood. The 
first important deterioration is to be apprehended at puberty. Then 
there is rapid further diminution, so that at the age of about 30 or 40 
there may be considerable loss of hearing ability. 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 231 

The prognosis is more favorable where the first signs of impaired 
hearing occur between the 20th and 30th year. In these cases the path- 
ological process may be arrested for a time, and there may even be 
transitory improvement. 

Otosclerosis is often associated with secondary psychic manifesta- 
tions. Patients appear apprehensive and depressed, this impression 
being increased by the pathological changes of the voice which will 
appear at a later stage. Children suffering from otosclerosis can follow 
their lessons only with the greatest exertion and display of the closest 
attention. For this reason general neurasthenic complaints will develop 
early, together with a tendency to pathological introspection. Patients 
are apt to regard all kinds of extraneous matters as the cause of the occur- 
rence or exacerbation of their trouble, and consequently develop early 
in youth a tendency to solitude and seclusion. This is intelligible when 
it is considered that school education is imparted to the growing child 
chiefly by word of mouth and that progressively deaf children have 
therefore enormous difficulties to overcome. As soon as the hearing 
acuity has diminished to 10-13 feet, the child is unable to follow his 
lessons any longer, and he should be instructed separately or assigned 
to a class for those difficult of hearing. The uncertainty of understand- 
ing strangers may also lead to numerous misunderstandings, psychic 
conflicts, and despondency. 

Diagnosis. — Politzer deserves the merit of having correctly formu- 
lated the clinical conception of otosclerosis. Accordingly, the diagnosis 
of typical otosclerosis is based on the following findings: The tympanic 
membrane and Eustachian tube are normal. Ventilation of the middle- 
ear spaces is perfectly normal. Functional test shows in the typical 
forms an obstacle to conduction (pathologically elongated bone-conduc- 
tion, c4 normal or slightly shortened, upper sound-limit normal). In 
atypical otosclerosis, labyrinth symptoms may likewise be present 
(lowering of the upper sound-limit, in advanced cases sound-islands). 
The affection shows a distinct hereditary and progressive character and 
is associated with subjective hearing perceptions. In simultaneous in- 
volvement of the static labyrinth there are vertigo and equilibrial dis- 
turbances. As to transitory forms, see p. 236. 

Early diagnosis in childhood may present difficulties owing to the 
fact that the condition of the tympanic membrane sometimes simulates 
a secretory catarrh. In these cases the diagnosis is often made on the 
proof of the hereditary character of the affection, and often also on the 
fact that after removal of the exudate insufflation of air will produce but 
slight improvement in hearing, if any. In ordinary exudative catarrh, 
however, the hearing acuity is at once increased to normal when air is 
insufflated. 



232 THE DISEASES OF CHILDREN 

An important diagnostic aid consists in the rose lustre of the prom- 
ontory, which was first observed by Schwarz and which is found in 
many cases where the posterosuperior quadrant fuses with the postero- 
inferior, corresponding to the convexity of the promontory. Its origin 
is possibly due to pathological vascularization and hyperaemia of the 
mucous membrane or perhaps of the bone of the middle wall of the 
tympanic cavity (see p. 236). It should, however, be mentioned that a 
rose lustre of the promontory may also occur in perfectly normal ears. 

Treatment. — Rational treatment in otosclerosis must start with 
the attempt at establishing the etiological factor. If a careful examina- 
tion has led to the positive result of a general affection, this should 
receive the greatest attention. If no general affection can be demon- 
strated, the mode and regimen of life should nevertheless be regulated, 
a proper climate selected, and a suitable diet prescribed. 

According to Politzer, high altitudes, sea air and bathing are not 
propitious, the best place to live in being one situated at a moderate 
altitude and in protected surroundings. 

Medication. — Small doses of potassium iodide and sodium iodide 
(0.25 Gm. per day for 3-4 weeks, twice a year) , iodipin, or Siebenmann's 
phosphorus medication (phosphorus 0.01 in 01. jecor. aselli 100.0, 1-2 
teaspoonfuls daily, continued for some time). 

Heimann looks upon phosphorus as invigorating, improving the 
general nutrition, but not as improving the pathological changes of the 
bone. Sugar recommends phytin in the place of phosphorus. The dose 
for children of from two to six years is 0.25-0.50 Gm., and for children 
from six to ten years 0.50 to 1 Gm. daily. 

According to Hammerschlag's experience in Politzer's clinic, thy- 
roidin treatment has in no way come up to expectations. However, 
owing to its iodine content, it may be tried. The subjective noises are 
sometimes relieved by bornyval. 

Any pathological changes of the nasal and nasopharyngeal mucosa 
should be corrected by the appropriate treatment. 

Local treatment of otosclerosis through the ear-speculum is, accord- 
ing to Politzer, not only useless, but in some cases injurious. On the other 
hand, in the first stages where the motility of the stapes plate in the oval 
window is not yet greatly impeded, pneumomassage through the external 
meatus produces better results as to hearing acuity than air insufflation 
through the tube. This procedure, however, may not be practised for 
more than J^-l minute, twice to three times weekly, and continued for 
about 4 weeks. After this a pause of several months must be observed. 

In some cases pilocarpinum hydrochloricum seems to have a favor- 
able effect. It should be injected through a catheter (3 or 4 drops of a 



AFFECTIONS OF THE CAPSULE OF THE LABYRINTH 233 

1 per cent, solution). Subcutaneous injections, which often cause 
manifestations of intoxication, had better be avoided in children. 

Zitowitsch recommends the faradic current, introducing the button 
electrode deep into the tubal canal, while the second electrode is applied 
between the mastoid and the submaxillary angle. 

Malutin reports good results from applying mud baths to the ear. 

Malherbe advises "transtympanic electro-ionization," in which he 
distinguishes between the direct and indirect method. In the direct 
method one electrode (the indifferent one) is introduced into the tube, 
while the other is placed in the auditory canal, which has been filled with 
fluid. In the indirect method the indifferent electrode is applied to any 
part of the body; the fluid exposed to ionization is either a 2 per cent, 
solution of pilocarpine or, better, a 1 per cent, solution of chloride of zinc. 

Ferreri's theory is to use diplococcus serum, partly on Wright's 
principle of vaccination and partly as instillation into the tube. 

Joulin reports 10 cases of otosclerosis which were remarkably im- 
proved by X-ray treatment. Schwarz treated 3 cases in this way, in 
one of which — a boy 16 years old — there was an almost complete cure 
after six radiations, given at the rate of one per month. These favorable 
results may be explained by the experimentally proved arrest of new- 
formation of bone under the influence of the X-ray. 

Although removing the stapes has been recommended, we advise 
against it, for the end results have not proven satisfactory owing to 
secondary infection or subsequent formation of adhesions. 



XI. AFFECTIONS OF THE INTERNAL EAR 

I. CONGENITAL ANOMALIES OF THE LABYRINTH 
1. CONGENITAL DEAFNESS DUE TO THE LABYRINTH 

A-positive etiological factor for this very rare affection, which occurs 
both uni- and bilaterally, has not yet been found, although in many cases 
there is an hereditary taint. Either the father or mother is partially or 
completely deaf or there is congenital deafness in the family or in that of 
blood relatives. In other cases, where there is no hereditary taint as to 
impaired hearing, there are other hereditary degenerative stigmata. 
Thus, congenital deafness due to the labyrinth may be associated with 
trifling anomalies of the face, extremities, or trunk; or there is a general 
nervous taint, affections of the nerves and brain in former generations, 
or there may be hereditary syphilis (q.v.). 

So far as the anatomically examined cases admit of a conclusion, 
the anatomical changes in this affection consist in congenital hypoplasia 
of the spiral ganglion and the peripheral portion of the cochlear nerve 
appertaining to it. The nuclei, roots, and central ramifications of the 
cochlear nerve, however, are perfectly intact. Corti's organ and the stria 
vascularis show various forms and degrees of degenerative atrophy, as 
in deafness of adults due to affections of the labyrinth. 

Hereditary pigment anomalies also occur in congenital deafness of 
adults (hereditary degenerative deaf-mutism, Hammerschlag). 

A classical example of congenital partial deafness is the following 
case which I observed and published : 

A boy, twelve years old, had been slightly deaf from earliest child- 
hood, maybe from birth. Mother and three younger children had normal 
hearing, but the father, then 54 years old, had been partially deaf from 
childhood. The father's affection had undergone no change in the course 
of years; vertigo or tinnitus had never occurred. Etiologically there was 
nothing positive to go upon; in both cases syphilis could be distinctly 
excluded, so that the auditory affection could only be assumed to be a 
congenital defect. 

Examination of the boy: Both tympanic membranes showed a 
distinct shadow, red-yellow in color, at the border between the postero- 
superior and inferior quadrant, corresponding to the region of the prom- 
ontory. Otherwise both tympanic membranes were unchanged. 
Functional test: Hearing acuity for both ears 37 feet for conversation, 
27 feet for .whispering, and 27 feet for the acoumeter. Weber not lateral- 
ized, Schwabach shortened, Rhine's test (c 1 ) positive on both sides, lower 
sound limit normal, upper sound limit reduced, c 4 (air-conduction) both 

234 



AFFECTIONS OF THE INTERNAL EAR 235 

sides distinctly shortened. Watch positive through the cranial bones. 
No pathological manifestations due to the semicircular canals or vestib- 
ulum, excitability normal, no spontaneous nystagmus. 

Diagnosis : Bilateral affection of the inner ear (labyrinth, auditory 
nerve), hyperemia (deduced from the promontorial shadow) of the 
lateral wall of the labyrinth (mucous membrane and osseous capsule of 
the labyrinth). 

Examination of the father: Both tympanic membranes normal. 
Functional test: Hearing acuity for conversation, right side 47 feet, 
left 27 feet; whispering, right side 10 feet, left 1 foot 8 inches; acoumeter, 
3 feet 4 inches right and left. Weber not lateralized, Schwabach con- 
siderably shortened, Rinne's test collaterally positive, lower sound limit 
normal, upper sound limit reduced, c 4 (air-conduction) considerably 
shortened, left more than right. Watch through cranial bone negative. 
No pathological manifestations of the semicircular canals or vestibulum ; 
reflex excitability of the static labyrinth normal; no spontaneous 
nystagmus. 

Diagnosis: Bilateral affection of the internal ear (labyrinth, auditory 
nerve) . 

According to these findings, there could be no doubt that the son's 
case was an hereditary-congenital affection of the labyrinth and was 
traceable to congenital changes (arrest of development) in the region of 
the nerve-ganglia, the cochlear nerve, or the membranous canal of the 
cochlea (Corti's organ). 

The case belongs to the group of those congenital changes which, 
if highly developed, will lead to congenital deafness. The rarity of the 
case is intensified by the fact of the promontory shining through the 
tympanic membrane, which is ordinarily considered a characteristic sign 
for the clinical findings in otosclerosis. The functional test, however, 
proved that this was not a case of typical otosclerosis. On the other 
hand, recent anatomical examinations have demonstrated the fact that 
those changes of the osseous labyrinth capsule which show a reddish 
shadow also occur — though rarely — in cases of congenital deafness and 
cretinism; in short, in various forms of congenital ear affections. The 
present case, however, shows that a light congenital affection of the 
labyrinth may also be associated with that form of bony changes. 

The rarity of these findings is explained by the fact that a slight 
impairment of hearing in children is easily overlooked and that these 
cases are not brought to the attention of the physician. The affection 
remains undiscovered unless it makes rapid headway at the time of 
puberty and leads to a higher grade of deafness. The relationship of 
these cases with the clinical forms of otosclerosis can no longer be doubted 
at the present time. Congenital anomalies of development in the region 



236 THE DISEASES OF CHILDREN 

of the cochlea and the auditory nerve no doubt represent the primordial 
changes in many cases of otosclerosis. To these changes are added the 
characteristically otosclerotic changes of the osseous labyrinth capsule, 
either at the embryonal or a later period. 

Symptoms. — If the affection occurs unilaterally without any mani- 
festations of the vestibular nerve, partial deafness due to the labyrinth 
may exist for years without any symptoms, unless it is accidentally dis- 
covered. Thus, owing to an intercurrent affection it may become neces- 
sary to examine the ear, or the child is suddenly found to be deaf if by 
chance the healthy ear is occluded, as may occur by lying on it in bed. 

Should the affection be bilateral or associated with vestibular 
symptoms, it will of course be discovered much sooner. The character- 
istic symptom will then in most cases consist in a moderate degree of 
deafness. Subjective noises do not seem to occur often before puberty. 
Should any subjective noise be present, it is usually perceived as a very 
high but not intense whistling sound. 

Vestibular symptoms are very rare. They consist in a slight reduction 
of the equilibrium, with consequent slight disturbances of gait (legs apart). 

I have never observed in these cases any symptom of the semi- 
circular canals in the shape of vertigo or vomiting. The reflex excita- 
bility of the static labyrinth was always normal. 

Course and Prognosis. — The prognosis in some cases is not unfavor- 
able, when the degree of deafness remains for life at the same low level 
or slightly increased. The critical age is the time of puberty. If at that 
period there is but slight decrease of the hearing acuity, or none at all, 
the prognosis remains favorable for the future. Similarly, in all cases 
in which the affection has occurred unilaterally and is not complicated 
by vestibular symptoms, the prognosis is favorable. On the other hand, 
in cases where the unilateral affection increases at the time of puberty, 
there is danger of the healthy ear becoming likewise affected. 

The prognosis is unfavorable in all such cases of bilateral labyrin- 
thine partial deafness in which the affection rapidly increases at the time 
of puberty and in which the history reveals a family taint in regard to 
congenital affections of the ear (hardness of hearing or congenital deaf- 
mutism) . The prognosis is also unfavorable in those cases in which there 
are not only cochlear but also vestibular anomalies. 

An improvement of the condition or a restoration of normal func- 
tion is quite out of the question. In stationary cases any kind of local 
treatment may therefore be discarded. In progressive cases systematic 
galvanization of the auditory nerve is indicated, one electrode being 
applied close above the tragus in the mastoid fossa, the other to the nape 
of the neck, chest, or hand. Some authors advise application of a divided 
anode to both ears, with the cathode at the nape of the neck, or galvaniza- 



AFFECTIONS OF THE INTERNAL EAR 237 

tion transversely through the head. The galvanic current is applied 3 
times a week for 5-6 weeks, after which a pause of 4-6 weeks should be 
observed. Besides, the use of iodine, phosphorus, iodine baths, or anti- 
syphilitic treatment (even in cases with negative history) is justified. 

2. CONGENITAL AFFECTIONS OF THE STATIC LABYRINTH 

These cases without exception furnish exceedingly interesting 
anomalies of reflex excitability of the semicircular canals. Thus, with 
an otherwise perfectly normal labyrinth the semicircular canals may be 
totally unsusceptible to the excitation of the rotatory chair. There is 
not the slightest vertigo or nystagmus after intense and long-continued 
rotation. But there is a positive reaction, which means positive and 
normal excitability, if the semicircular canals are tested by heat or elec- 
tricity instead of by rotation. There are other cases in which the caloric 
or galvanic excitability is negative while for other tests excitability is 
normal. 

Cases of this kind are rare and are only accidentally discovered on 
the occasion of other examinations of the ear. The congenital anomaly 
runs a perfectly symptomless course and does not cause the slightest 
complaint. Thus, the "galvanic insusceptibles" were accidentally dis- 
covered by Kreidl and Pollak on the occasion of the extensive investiga- 
tions of these authors into the behavior of individuals with normal 
labyrinths on rotation or galvanic excitation. 

The congenital anomalies of the static labyrinth also include over- 
excitability, as observed in hereditary syphilis, or abnormal excitability 
of the semicircular canals (q.v.). 

In these cases there is compression- or aspiration-nystagmus, whereas 
a normal static labyrinth does not react upon increased or diminished 
air-pressure in the ear or middle ear. 

The conditions for the other forms of excitability of the static 
labyrinth in these cases are normal, but in spite of increased mechanical 
excitability any one of the other forms may be temporarily or permanently 
diminished or destroyed. However, the positive mechanical excitability 
also seems to vary considerably in these cases. 

Of course, the question of treatment need not be taken into consider- 
ation in these cases. 

PROGRESSIVE PARTIAL DEAFNESS DUE TO THE LABYRINTH IN CHILDHOOD 

Politzer was the first to report cases in which there is rapidly in- 
creasing bilateral impairment of the auditory function toward the age 
of 20, which sooner or later leads to considerable reduction of the same 
or to absolute deafness. We are indebted to Manasse for valuable con- 
tributions as to the nature of these conditions. 



238 THE DISEASES OF CHILDREN 

The functional test in these cases shows all the symptoms of an 
affected sound-perceiving apparatus. According to Politzer, the ana- 
tomical cause of this affection is an idiopathic atrophy of the auditory 
nerve. It is questionable, however, whether all cases conform to a uni- 
form anatomical type. Part of the cases unquestionably are acquired 
partial deafness due to the labyrinth, but in another group of cases 
progressive hardness of hearing in childhood develops on the basis of a 
congenital labyrinthine partial deafness. 

The affection is nearly always confined to the cochlea and does not 
spread to the static labyrinth. In an etiological respect, hereditary 
taint of auricular or mental affections, or other important congenital 
anomalies of development, as well as hereditary syphilis, should be 
particularly mentioned. The chief and often only symptom of the affec- 
tion is a hardness of hearing, due to the labyrinth, which rapidly increases 
in short periods. Subjective noises occur but rarely in childhood. Exami- 
nation shows a normal tympanic membrane and no changes whatever 
of the middle ear, admitting without any doubt a diagnosis of a middle- 
ear affection. 

The affection occurs isolated at the auditory nerve, but may excep- 
tionally be associated with affections of other cerebral nerves, notably 
the optic and olfactory. 

Some of these cases belong to the domain of acromegaly, cranial 
deformities (oxycephalia), and the rarer affection of leontiasis ossea, in 
which the cerebral nerves are compressed in their canals by the osseous 
proliferation of the base of the skull and gradually atrophy. 

Treatment. — Unfortunately, treatment is hopeless, the prognosis 
being in all cases unfavorable. Therapeutic success cannot be thought 
of. Treatment is confined to galvanization of the auditory nerve and 
the internal administration of iodine and phosphorus. Sometimes 
salvarsan injections may be indicated. In acromegaly surgical treatment 
of the underlying affection should be considered. 

3. CONGENITAL DEAFNESS 

The etiological factors are not perfectly clear. It is certain, however, 
that many cases of congenital (co-procreative, Hammerschlag) deafness 
are the expression of general physical degeneration and therefore belong 
to the group of hereditary-degenerative deaf-mutism in Hammerschlag 's 
sense; nevertheless there are exceptional solitary cases of congenital 
deafness in healthy families with healthy parents and mentally normal, 
healthy children. 

Hereditary taint of congenital partial or total deafness in near or 
remote past generations plays an important part. In these cases there 
is sometimes congenital deafness in several children, but it is rare that 



AFFECTIONS OF THE INTERNAL EAR 239 

half the number of children are so afflicted. It is rarer still that the 
entire progeny should be born deaf, even where the family taint is excep- 
tionally severe. Consanguineous marriages are not conducive to patho- 
logical taints as long as both parents are physically and mentally sound 
and show no signs of vegetative or animal degeneration of any kind. 
Peiper's view is therefore to be assented to, that the progeny of con- 
sanguineous marriages between robust and healthy individuals is like- 
wise perfectly normal and robust. Even popular tradition may be cited, 
according to which popular heroes — individuals who excel the normal 
in every respect — are supposed to have been the offspring of brother and 
sister or other relatives. Similarly, the breeding experiments with 
animals show that aocouplement of healthy consanguineous animals by 
no means endangers the health of the young in the shape of any taint 
whatever. 

On the other hand, the statistical investigations made by Kreidl 
and myself have shown that consanguineous marriages of degenerates 
are a very considerable factor, regardless of whether both parents or 
only one are affected. The degenerative manifestations of the progeny 
of such parents include general deformities of the body as well as of the 
organs of special sense, among which the hearing faculty frequently takes 
rank. 

The taint of ear affections in the ancestors is not necessarily con- 
genital deafness or labyrinth affection at all. Any form of congenital 
ear affection, with otosclerosis in the forefront, and exceptionally even 
anomalies of development of the auditory canal and concha (atresia or 
other defects) in the ancestors, may be followed by congenital deafness 
or other congenital defects of the labyrinth in the immediate or remote 
offspring in future generations. 

Anatomy. — The anatomical foundation of any form of congenital 
deafness lies in pronounced anomalies of the cochlear nerve and its 
peripheral end apparatus, Corti's organ. 

In most of these cases there is an originally defective embryonal 
rudiment of the nerve-ganglia of the cochlea and Corti's organ (congenital 
hypoplasia of the cochlearis). In other cases the embryonal rudiment 
of these parts is normal, and there will be only secondary atrophy of the 
nerve-ganglia and a degeneration of Corti's organ, owing to defective or 
arrested development of the auxiliary apparatus of the cochlea and the 
rest of the ear (capsule of the labyrinth and tympanic cavity). 

Accordingly, two groups of congenital deafness may be distinguished : 

I. Congenital deafness from congenital aplasia or hypoplasia of the 
cochlear nerve, the spiral ganglion, and Corti's organ. 

II. Congenital deafness from atrophy of the cochlear nerve, spiral 
ganglion, and Corti's organ, owing to congenital defective or arrested 



240 THE DISEASES OF CHILDREN 

development in the area of the capsule of the labyrinth or of the middle 
ear. The comprehensive labors of Siebenmann and Denker are of great 
importance in relation to the classification of the various findings. 
I. In Group I there are the following subdivisions: 

(1) The congenital anomaly of the embryonal rudiment of the 
labyrinth may be confined to the cochlea. From this results the type 
of sacculo-cochlear degeneration : 

Semicircular canals and utriculus normal; the congenital anomaly 
of the labyrinth is restricted to the pars inferior. This type is found in 
about 70 per cent, of the congenitally deaf. The functional test shows 
normal semicircular canals and no equilibrial disturbances. 

The functional test methods of the vestibulum are not yet sufficiently 
advanced to allow of the recognition of the functional insufficiency of 
the macula sacculi as compared to the function of the intact macula 
utriculi. In about one-third of these cases circumscribed areas of Corti's 
organ and its apparatus of nerve-ganglia are functionally efficient, so 
that remnants of hearing ability may be observed. 

(2) Congenital hypoplasia comprises the entire apparatus of nerve- 
ganglia and the nerve-end places of the whole labyrinth. In these cases 
the entire eighth nerve in the internal auditory duct is as thin as a thread ; 
all the six nerve-end places of the labyrinth are merely indicated by 
accumulations of prop-cells or are entirely absent. In these cases there 
is complete deafness and absent excitability of the static labyrinth, com- 
bined with congenital equilibrial disturbances of the labyrinth. 

(3) Aplasia of the entire membranous labyrinth. This is of rare 
occurrence and of subordinate clinical importance. It is always a 
part manifestation of pronounced malformation of the brain and head 
(anencephalia, cyclopia) ; it may also be found in double monstrosities, 
in short in individuals who are either non- viable owing to other congenital 
defects, are stillborn, or will die within a few hours after birth. 

In all three forms of congenital deafness there are more or less 
important changes in the shape of the membranous labyrinth, aside from 
the anomalies described. 

Obliteration of the pars inferior of the membranous labyrinth is a 
typical condition in the sacculo-cochlear type. The hollow spaces of the 
membranous labyrinth may be either constricted or dilated. Further- 
more, abnormal embryonal folds have formed membranous septa which 
traverse the hollow spaces of the labyrinth or through which free parts 
of the membranous labyrinth may be encysted (membrana tectoria, 
otoliths) . 

The defective development of the sensory epithelium is, of course, 
associated with considerable epithelial metaplasias. In nearly every case 
belonging to this group there are large quantities of abnormal, bizarre 



AFFECTIONS OF THE INTERNAL EAR 241 

forms which in most cases belong to the prop-cell type, less often to the 
hair-cell type, aside from the few remaining normal epithelial cells. 

The totality of the degenerate combined epithelial cells of the mem- 
branous labyrinth may develop into pathological cell heaps which either 
remain attached to the membranous wall or are encysted in a double 
septum, or are freely suspended in the endolymphatic spaces. 

A typical accompanying manifestation of aplasia or hypoplasia of 
Corti's organ is aplasia or atrophy of the stria vascularis. 

II. Congenital deafness from atrophy of the cochlear nerve, spiral 
ganglion, and Corti's organ, owing to congenital defective or arrested 
development in the area of the capsule of the labyrinth or of the middle 
ear. To this group belong: 

(1) The anatomically interesting deformity of the membranous 
cochlear canal resulting from insufficient development of the osseous 
cochlear capsule. This type of congenital deafness in man was first 
demonstrated by myself, and in animals by Tandler and myself, — not 
by Mondini, as Siebenmann erroneously states. The embryonal mem- 
branous cochlear canal is first covered laterally by a cartilaginous crust, 
which gradually deepens and finally assumes the external shape of the 
later cochlea. A crest, which separates the vestibular section of the 
cochlear from the cochlear body, rises from the interior surface of this 
cartilaginous crust. 

Should the development of the cochlear capsule be arrested at this 
stage and lead to ossification, the other scala will fail to develop. The 
scala vestibuli will then communicate with the scala tympani of the 
next higher convolution, and the membranous cochlear canal will assume 
an entirely abnormal shape and position. In that case there will be 
abundant cell material in the area of the nerve-end places and their 
auxiliary apparatus, and the impression given by the histological picture 
is that the final anomalies of Corti's organ, the stria vascularis, and the 
membranous cochlear canal have developed at a later period, and as 
subsequent manifestations of the arrested development of the capsule of 
the labyrinth. 

(2) Pathological osseous foci in the capsule of the labyrinth, com- 
bined with degenerative atrophy of the nerve-end places of the labyrinth. 

The cases belonging to this group have been elucidated by the find- 
ings of Lindt, Manasse, Politzer, Siebenmann, and myself. 

The membranous labyrinth has a more or less normal shape, or 
there is congenital hypoplasia or aplasia of one or both vestibular sacs, 
the canalis reuniens, and the vestibular cul-de-sac. All the nerve-end 
places are atrophied, and the hair-cells are absent. There are patho- 
logical osseous foci in the capsule of the cochlea of the type of osteitis 
vasculosa. They entirely conform to those foci which characterize the 

VI— 16 



242 THE DISEASES OF CHILDREN 

anatomical findings in otosclerosis. In some cases there is also found 
constriction or osseous occlusion of the labyrinth windows and oblitera- 
tion of the cochlear aqueduct. 

The pathological osseous foci are situated in the lateral wall of the 
labyrinth, in the neighborhood of the windows of the labyrinth, in the 
promontory, or deep in the petrous bone. Siebenmann found osteitic 
osseous foci in the area of the semicircular canals and vestibulum, Manasse 
in the region of the internal auditory duct, and myself in the region of 
the internal auditory duct, of the basal wall of the cochlea, and of the 
vestibulum in a congenitally deaf cretin. 

This type of congenital deafness is a stepping-stone to the various 
forms of congenital hardness of hearing. There can be no doubt, in the 
light of our present experience, that in otosclerosis, too, the first rudiments 
of the pathological osseous foci are often of congenital origin, and that 
other changes of the capsule of the labyrinth, the ankylosis of the stapes, 
and the final destructive atrophy of the sensory epithelium are secondary, 
postembryonal defects. No doubt, congenital osseous foci of this descrip- 
tion may exist more or less without symptoms until puberty, and only 
then give rise to serious functional disturbance. 

(3) Congenital anomalies of the middle ear, combined with atrophy 
of the sensory epithelium of the labyrinth. This type of congenital 
deafness is best characterized by Siebenmann's findings. There are 
considerable anomalies in the chain of auricular ossicles, combined with 
atrophy and epithelial metaplasias of the membranous labyrinth. 

According to the findings in adult deaf-mutes, the perilymphatic 
tissue is usually atrophied and surprisingly poor in substance. 

(4) Congenital atresia of the middle ear is only rarely combined 
with congenital deafness. The most marked arrest of development in 
the majority of these cases occurs in the external and middle ear, without 
interfering with the development of the labyrinth. The functional test 
in patients with congenital atresia of the external auditory meatus shows 
in most cases normal function of the labyrinth. 

A. CLINICAL OB'SERVATIONS ON CONGENITAL AND ACQUIRED DEAFNESS 

AND DEAF-MUTISM 

Examination of these cases reveals either a normal or slightly changed 
tympanic membrane. Catarrhal changes of the middle ear and adenoid 
vegetations are not infrequent. Congenital anomalies of development 
of the concha or external auditory meatus are only exceptionally present 
in congenital deafness. 

The functional test of the internal ear is most important. 

It is to be found out whether deafness is complete or only partial. 
In the latter case the functional remnants must be determined in regard 



AFFECTIONS OF THE INTERNAL EAR 243 

to both quantity and quality. Itard's system of dividing the material 
in deaf-mute institutes into five groups is still the best for the quantita- 
tive determination. These groups are: 

( 1 ) Deaf-mutes with a hearing acuity of 6 feet 8 inches for conversation. 

(2) Deaf-mutes with retained perception of loud speech close to the ear. 

(3) Deaf-mutes with preserved vowel perception. 

(4) Deaf-mutes with preserved perception of loud noises (rattle, 
trumpet, whistle, hand-clapping, key-rattling, clock, alarm clock). 

(5) Total deaf -mutism (no functional remnants). 

The question whether there are any functional remnants at all can 
be determined in infants as young as six months, provided they are 
otherwise normal. The quantitative determination, according to the 
above five groups, is only possible at a higher age. Thus, for group 3 
the lowest limit is three years; for groups 1 and 2 the limit is 4-5 years. 
As to groups 1 and 2, children should have reached school age and perhaps 
have had some education either at home or at an institution for the 
deaf-mute. 

Should deaf-mutism be complicated by idiocy, it is difficult and some- 
times impossible, at any time of life, to diagnose whether there are any 
remnants of hearing ability. 

It is advisable to test each ear separately, closing the other ear with 
the finger or a cotton plug saturated with glycerin. In timid children the 
unilateral occlusion may be dispensed with ; instead, their attention should 
be diverted from the test by some toy given them to play with. The 
first part of the test would be to observe whether a sound or noise causes 
a motor reaction. The slightest degree of reaction consists in the child's 
eyes turning in the direction of the sound. A more decisive reaction 
consists in the head or body being turned, and the strongest reaction, 
which consists in starting up with a muscular contraction, can only be 
obtained by very powerful noises, unless there are considerable hearing 
remnants. 

In order to make a safe diagnosis, it is necessary that the child 
should react regularly upon the respective sounds, and that modifica- 
tions of the test should exclude errors due to tactile or optic sensations 
or suggestions. The examiner should stand behind the child without 
touching him, also taking care that the air current from the instruments 
used (rattle, whistle, trumpet) is not directed toward the body of the 
patient, lest the sensation cause a motor reaction without any perception 
of sound. 

If hearing remnants are to be determined in deaf-mutes who have 

already had lessons in lip-reading, the possibility of indirect reading 

should be reckoned with. The following is an interesting case in point : 

An intelligent boy eight years old was transferred to a new deaf-mute 



244 THE DISEASES OF CHILDREN 

institution, where a new examination for hearing was made. His face 
was turned toward the door, and the examiner, standing behind his back, 
was surprised by the considerable response he displayed, which could 
not have been expected considering his defective articulation. The 
explanation was forthcoming in a few minutes. The child observed the 
movements of the examiner's lips from the reflection in the highly-polished 
door and was thus able to read off the words indirectly. He did not have 
the slightest hearing remnants. 

A qualitative determination of any hearing remnants can, as a rule, 
only be made after the child has had some lessons in an institution. The 
examination consists in the monaural test with the hand-organ (har- 
monica) devised by Urbantschitsch or with Bezold's continuous tuning- 
forks, the object being to determine whether there are hearing remnants 
between b 8 and g 2 . Should this be the case, even though partly or slightly, 
the child can be instructed by the ear in the so-called hearing classes, 
with a fair chance of success. In some cases this test cannot be reliably 
made until the end of the first school year, in others not before the second 
or third year. 

The examination should be distributed over several sittings, as the 
child becomes easily fatigued and the entire examination occupies from 
one to two hours. 

The qualitative determination of any hearing remnants is only of 
practical value in institutions which have hearing classes, because here 
the hearing ability of the child is utilized, while in the other classes noth- 
ing but articulation and lip-reading is practised. As a matter of course, 
the lessons can be assimilated much quicker in hearing classes and a 
higher degree of learning be imparted. 

There are model hearing classes after Bezold at the deaf-mute 
institutions of Munich and Weissenfels. 

The presence of hearing remnants may also be deduced from the 
gait of deaf-mutes. Those totally deaf or with a nonfunctioning vestibu- 
laris drag their feet, when wearing shoes, causing a grating noise. They 
cannot hear the noise themselves, and, as the stability of their body is 
impaired, they are compelled to feel their way by a dragging manner of 
walking. Should, however, any hearing remnants be present, patients 
will perceive the noise they cause and avoid it. 

A second important sign is articulation. The sounds emitted by 
those totally deaf are always clumsy and inarticulate; they can only be 
produced with the aid of tactile sensation and optically acquired positions 
of the mouth and tongue. They know the intensity of the sound by the 
volume of air consumed, which they have learned to estimate by practice. 
They will be in a fight with their tongue to a certain extent for the rest 
of their lives, and will rapidly fatigue from using it. 



AFFECTIONS OF THE INTERNAL EAR 245 

Should, on the other hand, the slightest serviceable quantitative 
or qualitative remnants exist, deaf-mutes will make themselves under- 
stood, articulate cleverly and find something like correct intensity and 
modulation in conversational language, especially if any hearing remnants 
for words have been preserved. 

One should, therefore, never neglect to pay attention to the ordinary 
gait and speech of the deaf-mute when determining the presence of 
hearing remnants. 

The clinical examination of the static labyrinth of deaf-mutes has 
a certain value for the differential diagnosis. 

Most of those congenitally deaf-mute possess semicircular canals of 
normal reaction, and also a normal utriculus. The congenital affection 
is restricted to the pars inferior of the labyrinth, to the cochlea and 
sacculus. 

Two considerations will serve to explain this clinically established fact : 

Two organs of very different phylogenetic age are united in the 
membranous labyrinth. The static labyrinth — i.e., the vestibulum and 
the semicircular canals — is present down to a very low class of animals. 
Even the invertebrate animals possess a static labyrinth (statocyst) 
and in some plants cellular organs can be recognized which are homologous 
to the animal static labyrinth. 

The cochlea, on the other hand, is found only in animals of a higher 
degree of development, going upward from the amphibia, reptiles, and 
birds to the mammals. 

Now it is a well-known experience that the resisting power of an 
organ increases with its phylogenetic age, and it can, therefore, be well 
understood that a congenital injury leaves the static labyrinth unchanged, 
while it arrests the development of the cochlea. 

The second consideration arises from a histological examination of 
the nerve-ganglia. The nerve-ganglia of the cochlear nerve consist of con- 
siderably smaller cells and thinner nerve-fibres than those of the ves- 
tibularis, and the power of resistance to injury is the slighter, the tenderer 
the elements of which an organ is composed. 

Acquired Deafness. — Most cases of acquired deafness may be 
anatomically traced to inflammation of the labyrinth. The pathological 
factor exerts such an intense effect that usually the entire labyrinth 
(static and acoustic) perishes from the inflammation. 

The typical functional findings of acquired deafness, therefore, are: 
Total deafness, without any hearing remnants, and absence of excita- 
bility of the static labyrinth. In congenital deafness, on the other hand, 
the typical functional findings are preserved function of the static laby- 
rinth with preserved hearing remnants in a considerable percentage of 
cases. 



246 THE DISEASES OF CHILDREN 

Should the history be doubtful, congenital deafness can with cer- 
tainty be assumed from preserved excitability of the static labyrinth, 
and with great probability from preserved hearing remnants. 

B. DEAF-MUTE STATISTICS. EDUCATION OF THE DEAF-MUTE 

1. The Nwriber of Deaf-mutes in the Various Countries 

Excellent and exact statistical investigations have been made 
throughout Germany in conjunction with the census of December 1, 1900. 
The results were classified and published by the Imperial Board of Health. 
According to these figures, the total number of deaf-mutes was 48,750, 
of whom 54.1 per cent, were male and 45.9 per cent, female. The preva- 
lence of deaf-mutes in thinly populated country districts can be explained 
by the fact that the conditions of life and the hygienic facilities are less 
favorable there than in the cities or in districts which, owing to great 
fertility or favorable economic conditions, can offer better nutrition and 
hygienic protection. Of the total number mentioned, 75 per cent, were 
congenital and 25 per cent, acquired. 

As to Bavaria, there were 5281 deaf-mutes, 52.6 per cent, of whom 
were male and 47.4 per cent, female. 

A census in Austria at the end of 1905 showed 15,303 male and 12,264 
female deaf-mutes, — in all, 27,567. This shows a reduction by 300 as 
compared with 1904. Practically the same provinces in which cretinism 
is most prevalent have the greatest number of deaf-mutes: Carinthia, 
Salzburg, and Styria. 

Galicia has many deaf-mutes and few cretins, whereas in upper 
Austria and the Tyrol the reverse is the case. 

In Italy there are 38.8 deaf-mutes to every 10,000 inhabitants. 

In France there were 19,579 deaf-mutes in 1900. 

Belgium, with a population of 6,693,180, had 3500 deaf-mutes. 

In Spain there is 1 deaf-mute to every 2000 inhabitants. The total 
figure given of 7639 seems too low; 60 per cent, of these are said to be 
congenitally deaf. 

In Russia the total number of deaf-mutes has been estimated at 
more than 200,000. 

In 1894 a census of deaf-mute children was taken in Livonia. Result : 
61 below 8 years, 187 between 8 and 13, 819 above 13. 

Sweden registers 110.9 deaf-mutes to 100,000 inhabitants. Total 
number in 1890, 5307. 

In Norway there were 1176 deaf-mute men and 963 deaf-mute 
women in 1891; 1690 were congenital, 449 acquired; 514 were below the 
age of 15. 

Denmark, with a population of 2,200,000, has 1400 deaf-mutes, or 
60 per 100,000. 



AFFECTIONS OF THE INTERNAL EAR 



247 



In Finland there were 2767 deaf-mutes in 1890—1537 male and 1230 
female. 

Switzerland has 899 deaf-mute school-children. 

Holland has relatively the smallest number of deaf-mutes. - 

The number of deaf-mutes in the United States according to the 
census of 1900 numbered 89,287. 

2. Number of Deaf-mute Institutions 



Austria 26 

Belgium 12 

Canada 7 

Denmark 3 

England 70 

Finland 8 

France 67 

Germany '. 91 

Holland 4 



Hungary 8 

Italy 47 

Luxembourg 1 

Norway 5 

Russia 27 

Spain 11 

Sweden 7 

Switzerland 16 

United States 148 



Most of these institutions are equipped for resident patients, but 
they also treat outside patients. They usually admit boys as well as 
girls, but the education is mostly separate. Unfortunately, a large num- 
ber of these institutions are still conducted in conjunction with blind and 
orphan asylums. 

3. Number of Pupils Instructed Annually 

Austria 1,938 

Belgium. 1,265 

Canada 768 

Denmark 348 

England 4,222 

Finland 365 

France 4,098 

Germany 6,497 

Holland 504 



Hungary 550 

Italy 2,519 

Luxembourg 22 

Norway 309 

Russia 1,350 

Spain 475 

Sweden '. 803 

Switzerland 723 

United States 12,721 



In the German statistics for 1902 and 1905, 6689 question blanks 
regarding the degree of hearing remnants of 53 German institutions have 
been incorporated (3130 congenital, 3123 acquired, and 436 undecided 
cases) . The following is a summary of the collected material : 





l 


2 


3 


4 


Hearing remnants. 




5 


6 


7 


8 


Born deaf 


43.1 

46.7 
44.4 


11.8 
13.5 

12.8 


1.0 
1.7 

1.4 


8.0 
8.2 
7.9 


13.0 
12.0 
12.7 


2.9 
2.0 
2.5 


8.2 
6.2 
7.5 


12.0 




9.5 


All, including 436 doubtful ..... 


10.9 



1. Hearing entirely destroyed on both sides. 

2. Sound tested, but result not stated. 

3. Undecided sound-perception. 

4. Sound-perception. 

5. Vowels. 

6. Consonants, except p, t, r, k. 

7. Single words. 

8. Sentences. 



>> 



248 THE DISEASES OF CHILDREN 

Among the deaf-mutes in the German institutions 50.4 per cent 
showed deafness in "earliest childhood" and 49.6 per cent, "later. 
This nomenclature is by no means equivalent to congenital and acquired. 

4- Kindergartens and Preparatory Schools for the Deaf-mute 

In Berlin there is a Society for the Erection and Maintenance of 
Kindergartens fop Deaf-mute Children between the Ages of 3 and 7 
Years. The first kindergarten was opened April 1, 1894, with 8 children 
(later 14). The program was principally to impel children's attention by 
appropriate plays and occupation. No attempts are made at imparting 
speech. Much weight is attached to the nature of the occupation, 
physical care and education. The institution is under medical super- 
vision and direction. Individual medical examination is directed to 
constant observation of the hearing ability, speech and physical conduct. 

In England it has been possible by private donations to equip all deaf- 
mute institutes with classes for children under school age. Children under 

7 years are also instructed in special preparatory classes of the day-schools. 

In Sweden deaf-mute children are admitted to the kindergarten 
of hearing children after the system of Bell, of Washington, but, besides, 
receive a few hours' separate instruction daily by a special female teacher. 
A preparatory school for deaf-mutes exists in Gothenburg, where a 
trained deaf-mute teacher prepares children between the ages of 3 and 

8 years for the district school at Wenersborg. 

In Moscow a kindergarten for deaf-mutes has existed since 1900, 
in which children from 4 to 7 years old receive training and education. 

In France there are preparatory classes (classes enfantines) in the 
government deaf-mute institutes of Paris, Bordeaux, and Dijon. 

In Vienna the opening of a kindergarten for deaf-mutes who have 
attained school age is contemplated by the Imperial Deaf-mute Institute. 

5. Compulsory School Attendance 

In Germany and Austria deaf-mute children are included in the 
general law for compulsory school attendance. The number of deaf- 
mute institutes in Germany has increased to such an extent in the course 
of years that some of the federal states were in a position to accord instruc- 
tion and education to all deaf-mute children who are capable of following 
the lessons. It so happened, however, that the parents either opposed 
these humanitarian provisions or were indifferent to them, and conse- 
quently some of the states have found it necessary to introduce compul- 
sory attendance. The deaf-mute teachers have demanded compulsory 
attendance for years, at the same time furnishing proof by publications 
in their special journals of the disadvantages which would accrue from 
non-compulsory attendance. 



AFFECTIONS OF THE INTERNAL EAR 249 

In England every deaf-mute child is compelled to attend the day- 
school up to the sixteenth year. All city schools for deaf-mutes — that 
is, day-schools which are conducted by public committees — furnish 
instruction and education free of cost. For resident children or those 
assigned to foster-parents, the relatives contribute a sum according to 
their means. If they show that they are without means, both education 
and expense of living are furnished free. England, therefore, is the coun- 
try which takes the best care of its deaf-mute children. They are not 
admitted to ordinary public schools. 

In Sweden a special law for the instruction of deaf-mutes has existed 
for a long time. This law applies to (1) children who were born deaf or 
became so at an early age; (2) those who have become deaf after having 
learned to speak, but require instruction by deaf-mute teachers to pre- 
vent their becoming mute; (3) mentally defective deaf-mutes who can- 
not be instructed in a school for deaf-mutes. The object of the entire 
law is compulsory school attendance of all deaf-mutes. Children are 
compelled to attend school for 8 years, but on furnishing proof of adequate 
knowledge may be discharged earlier. 

As to Switzerland there are no generally applicable legal provisions 
for compulsory school attendance. The Canton of Berne, however, has 
a school-law to the effect that deaf-mute children capable of being taught, 
but unable to receive instruction in the public schools, will be assigned 
to special institutions or classes which are maintained by the state. 

Extensive provision for the instruction and training of all deaf-mutes 
has been made in the United States and Canada. 

Institutions for resident inmates preponderate in all the states, and 
it is only in this way that an undisturbed progressive instruction can 
be imparted. It is an important modern demand that the instruction 
be not arranged on too large a scale. An institution should not have 
more than 150 inmates. Boys and girls can be co-educated, but the 
various classes should not have more than 8-15 pupils each. 

There are a much smaller number of non-resident institutions, and 
the arrangement is here for children to be at home outside of school time. 
The resident institutions likewise recognize the high value of family 
education, and accordingly allow vacations at Christmas and Easter, 
during which the children are discharged for home. In selecting a deaf- 
mute institution it is also an important point to see that the child receives 
instructions in his native language. 

6. Advanced Education for Deaf-mutes 

An excellent school for advanced education for deaf-mutes is attached 
to the Imperial Deaf-mute Institute at Vienna. Instruction is here 
given in the evening and on Sunday mornings. Its object is to fortify 



250 THE DISEASES OF CHILDREN 

deaf-mutes in the knowledge they have already acquired and to equip 
them with such further knowledge as they will require for the practical 
purposes of life. The most important subjects taught are: drawing, 
commercial arithmetic, single-entry book-keeping, writing letters and 
business documents, economics. The advanced school is principally 
attended by those who, during school age, have already had instruction 
at the Imperial Deaf-mute Institute. In this way the sense is fostered 
of belonging together and of forming a bond of union which is a necessary 
adjunct to the success of the deaf-mute. 

There are similar schools for advanced education established by the 
Vienna Aid Society for Deaf-mutes and the Deaf-mute Institute at 
Prague. 

In Germany schools for advanced education are attached to a great 
number of deaf-mute institutes. 

In France schools for deaf-mute apprentices (ecoles professionelles) 
are attached to the deaf-mute institutes of Albi, Arras, Besancon, St. 
Cloud, Dijon, Elbeuf, Caen, Chambery, Limoges, LePuy, St. Etienne, 
Toulon, and at the National Deaf-mute Institute of Paris. In these 
workshops boys receive a thorough training. In Paris, for instance, the 
boys are instructed in horticulture, shoemaking, tailoring, printing, and 
wood-carving. An asylum with workshops for girls, who cannot return 
home to their families after leaving the school, exists in Bourg-la-Reine. 

In Belgium all inmates of deaf-mute institutes are taught skilled 
labor. The instruction commences at the age of 13. Previous to learn- 
ing the actual work, pupils are trained in Froebel work and modelling. 
In the selection of the work the wishes of parents and guardians are 
considered, but chiefly the aptitude and health of the boys and the con- 
ditions under which they will have to live later on. 

Spain seems to attach much weight to the professional education 
of deaf-mutes. In Madrid they are instructed in printing, bookbinding, 
shoemaking, wheelwright and locksmith work. The institutions at 
Bourgos and Seville are conducted on a similar plan. The tailors and 
shoemakers seem to make a fair living there, as special workshops for 
this kind of work are attached to the institutions. In the non-resident 
institutions of Barcelona, Valencia, and Saragossa, technical drawing 
and needlework for women are favorite subjects. 

England has evening schools aside from the day schools. They are 
attached to the various institutions as advanced classes and are main- 
tained by donations and government contributions. The subjects taught 
are the English language, wood-carving, cooking, and ladies' tailoring. 
There are also missions distributed all over England to aid and support 
adult deaf-mutes. Their special object is to promote the religious, social, 
and domestic life of the deaf-mute. Some of the deaf-mute societies 



AFFECTIONS OF THE INTERNAL EAR 251 

have made it imperative for their members to continue the sound language 
learned in the schools. 

Russia has appointed special workmen's teachers at the deaf-mute 
institutes. Pupils receive their technical training during school age. 
Warsaw has a Sunday-school for deaf-mute workmen. Moscow has an 
asylum for female deaf-mutes above school age and an aid society for 
adult deaf-mutes. 

In Denmark deaf-mutes are closely controlled both before and after 
school life in regard to occupation, marriage, and children. There are 
no special schools for advanced education. 

In Finland a number of advanced schools are maintained by the 
teachers for the benefit of their former pupils. Instruction is given 
during the vacations. A few deaf-mute societies have also arranged for 
advanced education for deaf-mutes. 

The institute at Groningen, Holland, is in the habit of sending to 
its former pupils so-called open letters with a view of keeping in touch 
with them after they have entered practical life. There are no advanced 
schools, but some such arrangement has recently been planned. 

An advanced mental education is accorded to deaf-mutes nowhere 
except in America, where pupils are even enabled to have college educa- 
tion. Advanced schools exist in nearly every large city in America and 
are closely connected with the excellent organizations there for adult 
deaf-mutes. 

7. The Choice of an Occupation for Deaf-mutes 

It is important to see that deaf-mutes learn a simple business which 
enables them to make a living and furnishes them with full occupation 
all the year around. Deaf-mutes, therefore, work as shoemakers, tailors, 
saddlers, bookbinders, gardeners, compositors, metal-workers, basket- 
makers, inside painters, lithographers, decorators, engravers, ornamental 
carpenters, sculptors, wood-carvers, etc. Conditions are less favorable 
for girls than for boys. They are generally occupied as seamstresses, 
tailoresses, milliners, ironers, flower-makers, cigarette-makers, or 
domestics. Both boys and girls do well in agriculture. 

When the instruction is completed, most of the deaf-mutes return 
to their native places. At a few Austrian institutes there is a special 
fund out of which poor apprentices are furnished with tools and clothing. 
At the places where there are institutes there are usually a number of 
resident employers who willingly take in apprentices in appreciation of 
their good ethical and physical qualities (attachment, industry, and 
manual dexterity). 

Pongratz has compiled statistics on the occupations and earnings 
of deaf-mutes in Bavaria, and thinks that those with a good training 



252 THE DISEASES OF CHILDREN 

will migrate into the cities where a greater number of them can find 
independent positions, as in regard to capability and earning power they 
are but little behind those in full possession of all their senses. 

In Belgium there are special instructors for nearly all occupations. 
If any particular occupation is not provided for, the directors of the 
institute send applicants to proper places where it can be learned. 

In England deaf-mutes, aside from many other occupations, are 
often employed by the post-office as sorters. They are excluded only 
from such work as might endanger them on the ground of deafness. 

In all Italian deaf-mute institutes there are classes for intellectual 
as well as industrial instruction. The former is based on the principle 
of verbal instruction; the latter depends on the future occupation. 

In Russia the pupils are left to themselves after school age. At the 
request of parents, however, the teachers find places for their pupils 
with some employer. A large number take up agriculture. At Mitau 
every deaf-mute was formerly compelled to become a tailor or a shoe- 
maker, but fortunately this compulsion is now abandoned. 

In Finland .most of the male deaf-mutes work on farms or in factories; 
the female ones work in tobacco or candy factories. 

In Switzerland the deaf-mute authorities object to the pupils going 
to the large cities and endeavor to find them employment in the neighbor- 
hood of their native places. 

In Holland there is compulsory education for both intellectual and 
industrial occupation, which is usually given in large workshops attached 
to the institutes. The instruction includes such occupations as tailors, 
shoemakers, carpenters, turners, vat-makers, printers, farmers for garden 
and field, but not all this at every institution. Girls learn ordinary and 
fancy needlework, measuring, cutting, and operating the sewing-machine. 
Those with particular aptitude are instructed in applied art, older ones 
in ironing and cooking. The Groningen report for 1900 has the following 
in regard to the earning power: "Although it is not to be expected that 
all discharged pupils will do equally well in the struggle for existence, 
yet most of them have been equipped sufficiently to earn at once part of 
their living." 

8. Provision for Deaf-mutes by Public Charity or Government Help 

At the end of 1900 there were in Germany 12 homes for deaf-mutes, 
the first object of which is to provide for poor old deaf-mutes who are 
unable to work. The care for the education of the deaf-mute devolves 
upon the provincial administrations. It was a gratifying advance in 
the development of the care for the deaf-mute in Germany when the 
provincial administrations took over the institutions. The number of 
institutions was greatly increased, a large number of new buildings were 



AFFECTIONS OF THE INTERNAL EAR 253 

erected, the time for education was prolonged, the industrial training 
of the pupils was improved, and the salaries of the teachers were increased. 

In Bavaria, according to the census for 1900, 491 deaf-mutes had 
been placed in homes (9.3 per cent, of all the deaf-mutes in Bavaria). 

In Austria the deaf-mute institutes are subordinate to the Imperial 
Ministry for Education in a pedagogic respect, but in all other respects 
they are subordinate to the various local authorities who see to their 
maintenance. There are no homes in Austria as yet for deaf-mutes, but 
there are deaf-mute societies in Vienna, Graz, Lemberg, Prague, Salzburg, 
which foster humanitarian objects. 

Of the 27,576 deaf-mutes living in Austria in 1905, 131, or 0.5 per 
cent., had been provided for by charity. 

In Italy the deaf-mute institutes of Genoa, Milan, Naples, Palermo, 
Rome, and Siena are maintained by the state. 

In Belgium the institutes for the deaf-mute and the blind are sub- 
ordinate to the Ministry of Justice as benevolent institutions. There 
are 4 asylums for female deaf-mutes (Brussels, Bruges, Ghent, Namur). 
The one at Namur also admits uneducated female deaf-mutes, also 
mentally afflicted and poor female orphans, the sick, and those who wish 
to enter a holy order. At Antwerp, Brussels, Charleroi, Ghent, Liege, 
Namur, and other cities there are societies for mutual aid, finding work, 
refuges, etc. All these societies formed a federation in 1901 at the III 
National Congress at Lourrain, through which the well-being of the 
deaf-mute is to be promoted. 

The local authorities in Belgium are obliged to send poor deaf-mute 
children into a special institute and to leave them there until they have 
attained mental and industrial efficiency. At the age of 65 every poor 
deaf-mute is entitled to a pension of 65 francs a year. 

The English institutions are maintained out of state and private 
means. 

The Russian institutions are chiefly dependent on private donations 
and exist usually as society institutions. Homes for the deaf-mute do 
not exist as yet in Russia. 

In Sweden a number of aid societies have been formed by adult 
deaf-mutes, among which the one at Stockholm is the largest and richest. 
The institutions themselves in Sweden and Norway are maintained out 
of state and private means. 

In Denmark there are several homes for adult deaf-mutes who are 
unable to work and for old men. 

In Finland a society for the care of the deaf-mute comprises the 
whole country. 

In Switzerland there are no homes whatever for the deaf-mute, 
but the institution at Zurich has been left a legacy to establish one, 



254 THE DISEASES OF CHILDREN 

so that probably Zurich will have the first home for old deaf-mutes 
unable to work. 

The Swiss institutions are maintained out of public and private 
means. 

In Holland public charity almost exclusively supplies the needs of 
the deaf-mute. 

A large number of humanitarian institutions provide for the needs 
of adult and old deaf-mutes in America. There are also special libraries 
and evening schools for adult deaf-mutes. 

9. Education and Provision for the Deaf-mute Blind 

As to Germany, Riemann, teacher at the Royal Deaf-mute Institute, 
deserves credit for what he has done in the interests of the blind deaf- 
mute. There are homes for the blind deaf-mute at Nowawes and Ketsch- 
endorf, near Fiirstenwalde. 

In Sweden there is a school home for blind deaf-mutes, which was 
erected in Skara in 1886 and transferred to Wenersdorf in 1892. Among 
the pupils a boy and a girl have shown unusual intellectual development 
which bears comparison to that of the well-known Laura Bridgman and 
Helen Keller. The instruction was given by the ordinary hand alphabet 
method. Having thus been introduced into an understanding of the 
language, they also learned to speak. Aside from the blind deaf-mutes, 
there are also several mentally afflicted and blind children at this insti- 
tution, which receives a large yearly contribution from the state. 

The department school at Hamar, Norway, reports a few successful 
results in the education of blind deaf-mutes. 

The case of Helen Keller, of Boston, is widely known, as, thanks to 
an exceptionally gifted teacher, she has attained a high degree of culture. 

C. DEAF-MUTE INSTRUCTION 

Both congenital and acquired deaf-mutism are in a general way 
preeminently a disease of the poor. The active factors which lead to 
congenital deafness are in many cases furnished or favored by the poverty 
of the parents. In acquired deaf-mutism the poverty of the family is a 
still greater factor. It is well known that cerebrospinal meningitis 
occurs oftener among the poor than the rich classes. In acquired deaf- 
ness resulting from scarlet fever, measles, etc., poverty again plays a 
role, since with good hygienic precautions and timely competent treat- 
ment most acute infections run their course without any ear complica- 
tions, or they are confined to the middle ear, and a spreading of the 
inflammation to the labyrinth is hardly to be apprehended. The hygienic 
precautions also include the timely removal of the faucial tonsils. Of 
course, we know that children with considerably increased lymphadenoid 



AFFECTIONS OF THE INTERNAL EAR 255 

tissue in the nasopharyngeal space are more prone to contract ear inflam- 
mations in the course of acute infections than children with a free passage 
in the nasopharynx. 

The deaf-mute child can have his school education privately in his 
family or as a resident or non-resident pupil of a deaf-mute institute. 
Owing to extraneous circumstances, the majority of deaf-mute cases 
must be admitted to institutions as resident patients. 

The deaf-mute child is placed in the institution at the age of seven 
or eight years, where he will remain, with the exception of vacations, 
until he has completed his eighth school year. It seems that the institu- 
tions answer their purpose best if they do not admit more than 150 pupils. 

The entire program of instruction also makes it desirable that a 
class should not consist of more than from eight to fifteen pupils. In- 
struction in a deaf-mute institute is more effective the closer it approaches 
personal instruction. All the pedagogic demands in regard to the con- 
sideration of the individuality of the pupil, which are of the greatest 
importance even for normal pupils, gain in importance when children 
with only four senses are concerned. The instruction consists in teaching 
lip-reading and articulation, and with these methods the subjects taught 
in public schools are mastered in the course of eight years. 

At the same time, sign language as a substitute for speaking is 
learned and used, but there is no regular instruction in this subject. 
New pupils readily learn the same from the older ones, as the child 
prefers using it at play and at work rather than making sounds. Re- 
cently it was suggested to give systematic instruction in gesticulation. 
The great practical use deaf-mutes can make of it, especially in convers- 
ing with each other, seems to lend weight to the suggestion ; but it cannot 
be denied that, as compared with instruction in lip-reading and articu- 
lation, sign language is of secondary importance. The understanding 
of higher conceptions, the formulation of conceptions, and the ethical 
development of the deaf-mute children, alike are inseparably bound up 
with the method of articulation and lip-reading. By using pure sign 
language it is impossible to impart higher conceptions to the child. 
Nevertheless, the suggestion of Kiimmel and Passow to give systematic 
instruction in preparatory schools to be newly founded is a salutary one, 
as instruction in articulation can be built upon the knowledge acquired 
by the sign language. 

Urbantschitsch has repeatedly emphasized the importance of hear- 
ing exercises. These exercises, for which he has arranged methodic 
instruction, are intended to initiate the understanding of the auditory 
impressions received, to help explain their meaning, to stimulate atten- 
tion for the various auditory perceptions, and to increase the sound- 
perception. 



256 THE DISEASES OF CHILDREN 

Urbantschitsch also recommends to extend instruction by the ear 
only to those deaf-mute children who possess relatively large hearing 
remnants, but disagrees with Bezold that those unable to hear the tun- 
ing-fork from a 1 to b 2 should be excluded from the hearing lessons. 

Bezold's suggestion to inaugurate hearing classes has borne good 
fruit. Only such pupils as are provided with hearing remnants qualita- 
tively and quantitatively sufficient to follow the instructions by the ear 
are admitted. It is advisable to place pupils from various institutions 
whose hearing properties are the same together in one class, as it is 
unlikely that one single institution has enough material to form such 
classes. The success which has attended the hearing classes is very 
satisfactory, as the subjects can be mastered quicker in these classes 
and higher instruction imparted. Of course, it has always been known 
that articulation in children with serviceable hearing remnants is in- 
comparably better than that of deaf-mutes. 

Hartmann's auxiliary schools occupy a medium stage between the 
hearing classes and normal schools. These schools are intended for 
children with partial deafness whose hearing ability is not sufficient to 
follow instructions in normal schools (congenital deafness under 6 feet 
8 inches, acquired deafness under 1 foot 8 inches, loud language, pro- 
vided the child has been able to speak before and has not yet completely 
unlearned it). According to Hartmann's statistics, it would be necessary 
to open schools for children with partial deafness in all cities of 150,000- 
200,000 inhabitants. 

The care for the deaf-mute before school age still leaves much to be 
desired in Europe. In America the deaf-mute institutes before the school 
age do excellent work. They are conducted on the principle of the Ger- 
man kindergartens. Parents are entirely relieved of the care for the deaf- 
mute children. The opening of similar institutes in Germany at an early 
date is urgently to be wished for. Kindergartens for deaf-mutes would 
facilitate later instruction in the institutes not only in a somatic, but also 
in an intellectual respect. In the kindergarten itself, at play and at work, 
deaf-mute children preferably use the sign language to converse with each 
other, but under the guidance of competent teachers they will acquire a 
thorough knowledge of lip-reading and articulation. 

II. INFLAMMATORY AFFECTIONS OF THE LABYRINTH 

Etiology. — Inflammation of the labyrinth may occur in the course 
of general affections, poisoning, or traumatic injury to the head or ear; 
as a rule, however, it is caused by some inflammation in the neighborhood 
(middle ear, endocranium) spreading to the labyrinth. 

According to their origin, suppuration of the labyrinth is divided 
into meningitic and otitic forms. The former occurs by the spreading 



AFFECTIONS OF THE INTERNAL EAR 257 

of a suppurative process from the brain and meninges to the labyrinth; 
the latter, by the spreading of a middle-ear affection to the internal ear. 
The involvement of the labyrinth itself occurs either by direct spreading 
of the suppuration by continuity or by metastasis. Suppuration of the 
labyrinth which has developed in the wake of endocranial affections is 
always caused by continuity of process. Otitic suppuration of the 
labyrinth, however, may have been caused by direct spreading of an 
infection as well as by metastasis. 

Anatomy. — The suppurative inflammation in the hollow spaces of 
the labyrinth itself is designated empyema of the labyrinth, unless the 
surrounding bone has been involved in the inflammation. The accumu- 
lation of pus in the endolymphatic spaces is called endolabyrinthitis, 
the one in the perilymphatic spaces perilabyrinthitis. Suppurative 
paralabyrinthitis is suppurative inflammation of the osseous capsule of 
the labyrinth and petrous bone in the immediate vicinity. 

Suppuration of the labyrinth is divided into diffuse and circum- 
scribed, according to the way it has spread. 

Suppuration of the labyrinth is diffuse if it extends to all the hol- 
low spaces of the ear labyrinth, semicircular canals, vestibulum, and 
cochlea. If part of the spaces is exempt, the suppuration is called cir- 
cumscribed. 

Suppurative inflammation of the labyrinth is either acute, subacute, 
or chronic, according to the duration of the process. 

In regard to the behavior of the neighboring parts, there are to be 
distinguished : 

(1) Empyema of the labyrinth if there is accumulation of pus in 
the interior of the labyrinth but the surrounding bone is unchanged. 

(2) Suppuration of the labyrinth with purulent paralabyrinthitis 
if the bone in the vicinity of the suppurative labyrinth has likewise 
undergone an inflammatory change. 

(3) Suppuration of the labyrinth with purulent paralabyrinthitis 
and fistula formation if there is suppuration of the soft labyrinth and a 
pathological communication has been established between the spaces of 
the labyrinth and the hollow spaces of the neighborhood. 

Suppurative inflammation of the labyrinth is always infectious. 
Pathogenic micro-organisms can always be demonstrated by microscope 
as well as culture. Acute empyema of the labyrinth sets in with pro- 
nounced hyperaemia of the entire soft labyrinth. There is early coagula- 
tion of perilymph and endolymph, purulent decomposition of the coagu- 
lated masses, and destruction of the entire soft labyrinth. The canals 
through which the hollow spaces of the labyrinth normally communicate 
with their surroundings (aqueducts of the vestibulum and cochlea, the 
lymph fissures along the nerve canals of the petrous bone) are occluded 

VI— 17 



258 



THE DISEASES OF CHILDREN 



by fibrinous masses. The nerve-end places perish by cell necrosis as 
early as the first stages of the inflammation. The entire labyrinth per- 
manently loses its function. The empyema, however, may persist un- 
changed for several months longer. A cure is gradually effected in favor- 
able cases by resorption of the pus and by connective-tissue formation, 
which later changes into bone. In other cases the empyema will perfo- 
rate outward into the middle ear or inward toward the endocranium into 
the middle or posterior cranial fossa. The perforation occurs by means of 
a fistula. 

If the softening of the bone spreads from the fistular region to the 
rest of the petrous bone, the ultimate consequence will be caries or ne- 

Fig. 93. 




Suppurative paralabyrinthitis of the lateral wall of the labyrinth with carious destruction of the osseous 
wallof the auditory canal (a). Natural size. A, antrum mastoideum; Pt, paries tegminis; VII, canal of facialis; 
c, destruction of bone at the anterior portion of promontory and at the tympanic tubal ostium; Cc, canalis 
caroticus; P, promontory; Fv, fenestra vestibuli; b, destruction of lateral wall of the canalis facialis. 



crosis of the labyrinthine nucleus of the petrous bone, or, less frequently, 
sequestration of the petrous bone itself, which is especially liable to 
happen in chronic tuberculosis of the labyrinth. 

Suppuration in the neighborhood of the labyrinth will spread either 
by normal preformed anatomical routes or by pathologically formed 
canals. A suppurative process of the meninges may spread to the laby- 
rinth by way of the internal auditory canal or the cochlear aqueduct, 
without causing any changes of the petrous bone. In all other cases 
of meningitic suppuration of the labyrinth and in all cases of otitic 
suppuration of the labyrinth, the direct spreading of the pus to the 
labyrinth occurs by way of fistulse. Infection of the internal audi- 
tory canal occurs by way of the facial canal in those rare cases in 
which the pus accumulated in the middle ear can spread along the 



AFFECTIONS OF THE INTERNAL EAR 



259 



nerve-sheaths of the facial by a congenital cleft of the osseous canal 
or a fistula. 

Suppurative inflammation of the osseous capsule of the labyrinth 
(paralabyrinthitis) does not lead to any changes of the labyrinth spaces, 
as long as it does not reach the cortex which protects the spaces of 
the labyrinth. Should, however, the suppurative inflammation have 
advanced to the endosteum of the labyrinth spaces (perilabyrinthitis), 
there will be an inflammatory thickening of the endosteal layer of the 
perilymphatic tissue in the region of the fistula, followed by coagulation 
of the perilymph and endolymph, abundant quantities of mononuclear 
and polynuclear leucocytes in the lymph-spaces of the ear labyrinth, 




Suppurative ostitis of the capsule of the labyrinth. Size 3.5: 1. , Csl, fistula of the lateral semicircular 
canal; VII, canalis facialis destroyed by suppuration; Sta, stapes; Cc, canalis caroticus; b, suppurative focus 
in the canalis caroticus; c, suppurative focus in the hypotympanum; P, promontory. 



considerable thickening of the walls of the membranous labyrinth, and 
finally disintegration of the sensory epithelium at the nerve-end places. 
It is possible for the entire labyrinth to be involved in these changes or 
for the inflammatory manifestations to confine themselves to a part of 
the labyrinth. The process spreads chiefly by continuity of the peri- 
lymphatic spaces. 

The labyrinth is divided into two compartments by the perilym- 
phatic connective-tissue septum demarcating the cisterna perilymphat- 
ica vestibuli. One of these compartments contains the cochlea, the 
sacculus, and the cisterna vestibuli; the other one contains the semi- 
circular canals, the ampullae, and the recessus ellipticus. The resisting 
power of the connective- tissue septum, especially if it is thickened by 



260 



THE DISEASES OF CHILDREN 



inflammatory infiltration, is sufficient to keep a circumscribed suppura- 
tion localized for some time in one of the two compartments of the 
labyrinth. Such a suppuration can even be confined for a short time to 
the lateral or posterosuperior semicircular canal. As a general rule, 
however, a circumscribed suppuration of the labyrinth will take place 
only in the acute or subacute stages, the type of the chronic suppuration 
being diffusely distributed over the entire labyrinth. Chronic circum- 
scribed suppuration occurs only in those exceptional cases where a 
certain section of the labyrinth has been completely isolated from the 
other spaces by the formation of small sequestra or by a cholesteatoma. 
A cholesteatoma of the labyrinth occurs from a middle-ear choles- 
teatoma, situated in the antrum or vestibular window, spreading to the 



VII 




Carie9 of the petrous bone. All the spaces of the labyrinth are patent, owing to fistulae. Csl, fistula of 
the lateral semicircular canal; V, fistula of the vestibulum; C, fistula of the cochlea; Cc, caries of the canalis 
caroticus; a, caries of the hypotympanum; VII, external wall of the canalis facialis is destroyed. 

labyrinth. In this process there is usually extensive destruction of the 
petrous bone. Cases where the cholesteatoma spreads from a fistula to 
the labyrinth spaces without causing extensive bony changes are rare. 

The thin osseous trabecule (crista vestibuli, scala, modiolus, lam- 
ina spiralis) are entirely destroyed by the chronic suppuration or the 
cholesteatoma of the labyrinth. That part of the petrous bone which is 
situated between the labyrinth and dura is likewise gradually destroyed. 
The final result is pachymeningitis externa, extradural abscess, and, 
finally, suppurative meningitis or cerebral abscess, with or without 
fistulous perforation into the dura. Suppuration of the labyrinth is 
often responsible for endocranial complications of the medial cranial 
fossa; should it occur, it almost invariably starts from a fistula or sup- 
puration of the bone at the vertex of the upper semicircular canal. The 



AFFECTIONS OF THE INTERNAL EAR 



261 



typical endocranial field of extension for a suppuration of the labyrinth is 
the posterior cranial fossa, more than 80 per cent, of the otitic cerebellar 
abscesses being etiologically traceable to suppuration of the labyrinth. 

Symptomatology. — The following table will be useful in the study of 
the course of symptoms in diffuse, acute or chronic, suppurative laby- 
rinthitis. 



Spontaneous nystagmus 

Vertigo 

Equilibrial disturbances 
Reflex excitability of 

the static labyrinth 
Hearing acuity 



Normal 



Normal 

+ 



Initial 
stage 



Bilat'l 

<P or + 

9 
Normal 

+ 



II 

Stage of 

inflammatory 

irritation 



To affect, side 

+ or <p 

+ . 

Pathologically 

increased 

+ 



III 

Stage of inflammatory 
paralysis 



IV V 

Perma- 
Stage of nent find- 
healing ings after 
recovery 



To the healthy side Bilat'l 

+ or <p 
+ 
Pathologically re- 
duced or negative 

+ or <p 



o 
+ 



The division into five stages absolutely conforms to practical clin- 
ical experience. It should, of course, be considered that the transition 
from one stage into another is not necessarily distinct, as a given 
case may, for instance, present the symptom-complex of Stage I at one 
time and that of Stage II at another. Should vertigo occur in the begin- 
ning of the affection, the symptoms of Stage II will be found during the 
attack as well as a short time before and after, — namely, nystagmus 
toward the affecte'd side and pathologically increased excitability of the 
labyrinth. The same patient, however, may present the symptom- 
complex of Stage I for a few weeks more when free from paroxysms : 
excitability of the labyrinth normal again and bilateral nystagmus. 

The transition of Stage II into Stage III in suppuration of the 
labyrinth usually occurs with a violent paroxysm of rotatory vertigo. 
Deafness will set in simultaneously. If the hearing ability had pre- 
viously been much reduced, the onset of deafness may escape the at- 
tention of the patient, especially if the hearing distance of the other ear 
is normal. 

Nystagmus now occurs toward the non-affected side. The direc- 
tion of the apparent rotation of the surroundings usually agrees with 
the direction of the nystagmus. While the patient previously perceived 
the apparent rotation of his surroundings toward the side of the affected 
ear, he now perceives it in the opposite direction. Patients rarely ex- 
perience apparent rotation of their own body. During the violent par- 
oxysm the nystagmus is very intense, rotatory, sometimes with a hori- 
zontal component. Usually, however, the intensity of the nystagmus is 
considerably relieved in a few hours, and in uncomplicated cases it is 
small and of slight intensity a few days later. The attack of vertigo is 



262 THE DISEASES OF CHILDREN 

sometimes of short duration, but in other cases it may last for several 
hours or days. The patient is unable to leave the bed, as the slightest 
movement, even the attempt to sit up in bed, brings on a violent acces- 
sion of vertigo. Such an attack is also accompanied by subjective noises 
(tinnitus, ringing, etc.), nausea, and vomiting. 

When labyrinthitis passes from the stage of inflammatory irritation 
into that of inflammatory paralysis, there is usually but one paroxysm 
of vertigo as the expression of the destruction of the nerve-end places 
(Stage III). In uncomplicated cases the vertigo attacks have now usu- 
ally come to an end. Should, however, the excitability of the labyrinth 
not yet be completely destroyed, other less severe attacks may follow, 
which will cease after the membranous labyrinth has been destroyed by 
suppuration. After the attacks have ceased, there is still a slight sensa- 
tion of continuous vertigo for a few days longer. This is gradually super- 
seded by equilibrial disturbances, which, finally, likewise disappear. A 
careful examination is now necessary in order to discover to what extent 
the equilibrium has been disturbed by the destruction of the labyrinth. 

Gradually, transition into Stage IV will take place. Spontaneous 
nystagmus toward the affected side is again demonstrable, but of less 
intensity. As time goes on, it may only occasionally be demonstrable 
or will completely disappear at the end of from six to eight months. 

The course of uncomplicated suppuration of the labyrinth, there- 
fore, extends over two to three months, counting from the beginning 
of the labyrinth symptoms and regarding the suppuration as terminated 
as soon as the spontaneous nystagmus has become very slight, and is 
directed toward both sides (to the right when looking to the right, and 
to the left when looking to the left). 

1. ACUTE SUPPURATIVE PARALABYRINTHITIS WITH FISTULA 

FORMATION 

It must be our endeavor to describe the various forms of inflam- 
matory affections of the labyrinth as single clinical pathological pic- 
tures. In this way it is possible to take up separately the type of para- 
labyrinthitis with fistula formation, which deserves special clinical and 
anatomical interest. 

Anatomy. — Acute paralabyrinthitis consists in suppurative inflam- 
mation of the lateral wall of the labyrinth and petrous bone in the region 
of the capsule. The suppurative inflammation of the bone extends up 
to the labyrinth. As a rule, erosion of the osseous capsule occurs in the 
area of the lateral semicircular canal, and, should the capsule be entirely 
destroyed, there will be diffuse suppuration of the labyrinth. 

In cases which take a favorable course, there will be complete clos- 
ure of the fistula, the function of the internal ear being retained. 



AFFECTIONS OF THE INTERNAL EAR 263 

It is uncertain whether the origin of the affection is favored by any- 
special anatomical feature of the petrous bone. It would seem prob- 
able, however, that paralabyrinthitis has a better chance of develop- 
ment where there are extensive diploic or pneumatic spaces in the pyra- 
mid of the petrous bone than where the latter is composed of compact 
bone. 

Occurrence, Symptoms, and Course. — Acute paralabyrinthitis with 
fistula formation more frequently follows in the wake of subacute than 
of chronic middle-ear suppurations, which extend to the antrum and 
mastoid process. It occurs exclusively in cases with repeated mani- 
festations of pus retention in the middle ear and greatly reduced hearing 
ability during the whole course of the suppuration (conversation, 3 feet 
4 inches). Participation of the antrum in the suppurative inflammation 
is indicated in these cases by early descent of the posterosuperior wall 
of the auditory canal. Spreading of the suppuration to the petrous bone 
and development of paralabyrinthitis are often favored by neglecting 
to open the mastoid process in time. 

In these cases paralabyrinthitis may set in without any special 
symptoms, since headache, sensation of fulness in the ear, reduced hear- 
ing distance, and descent of the posterosuperior wall of the auditory 
canal may have existed previously. Slight spontaneous nystagmus 
(bilateral with lateral vision) is taken as an early symptom; sometimes 
there is also slight vertigo, which, however, is not characteristic. Usually, 
therefore, the alarming symptom of a sudden violent paroxysm of 
vertigo comes as a surprise. 

Examination reveals violent nystagmus toward the affected side 
which occurs with vision toward the same side, often with straight 
vision or, in cases where the nystagmus is strongly pronounced, even 
with vision toward the opposite side. A distinct symptom of fistula can 
be produced in all these cases by pressing the tragus against the auditory 
meatus, which may cause a violent paroxysm of vertigo and a nystagmus- 
like slow movement of both bulbi toward the healthy side. 

Diagnosis. — The diagnosis is not difficult. Paralabyrinthitis should 
be at once considered if in the course of a subacute middle-ear suppura- 
tion there occurs a paroxysm of vertigo due to the labyrinth. The 
characteristic diffusion of the disease is recognized by the positive 
fistular symptom. 

Treatment. — Immediate antrotomy with broad incision of the 
antrum is indicated in paralabyrinthitis occurring in the course of an 
acute or subacute otitis. In subacute middle-ear suppuration these 
cases of paralabyrinthitis are not infrequently complicated by an extra- 
dural or mastoid abscess, from which descending abscesses will develop. 
The positive fistular symptom can be distinctly established during the 



264 THE DISEASES OF CHILDREN 

operation or during anaesthesia, a cotton tip advanced toward the 
antrum leading to a slow movement of the bulbi toward the healthy side. 

Immediate radical operation is indicated where paralabyrinthitis 
has been caused by a chronic middle-ear suppuration. 

Prognosis and course are favorable. 

All the complaints disappear after the performance of antrotomy. 
The after-treatment does not differ from that in an ordinary antrot- 
omy. Healing occurs in from six to eight weeks. The nystagmus 
toward the affected side disappears a short time after the operation; 
bilateral spontaneous nystagmus may persist for several weeks, but 
will gradually disappear. The fistula seems to close rapidly. In 
all these cases the normal function of the semicircular canals is per- 
fectly retained, the hearing acuity rapidly improves, and patients will 
in most cases only experience a moderate reduction in their former 
hearing acuity. 

The chronic cases may sometimes retain a satisfactory hearing 
acuity, but often there is a postoperative gradual decrease, until finally 
deafness sets in. 

2. LABYRINTHITIS SEROSA 

Etiology. — Labyrinthitis serosa occurs in rare cases as an inde- 
pendent affection of the ear, more frequently as a result of a traumatic 
injury to the head. It then assumes more or less completely the type 
of so-called traumatic concussion of the labyrinth. The occurrence of 
serous labyrinthitis as a complication of an affection of the middle ear 
seems to be intimately connected with the presence of a suppurative 
paralabyrinthitis which, up to the time, failed to present any symptoms. 
Under these circumstances it is possible for serous labyrinthitis to per- 
forate through a trauma. Consequently it may occur in the course of 
acute as well as chronic suppuration of the middle ear. Serous labyrin- 
thitis also includes the postoperative form which occurs in the wake of 
radical operations, after chronic suppuration of the middle ear has 
already induced superficial suppurative inflammation and erosion of the 
bone, which means that a superficial paralabyrinthitis has developed. 

The symptoms of serous labyrinthitis consist in the sudden onset 
of vertigo due to the labyrinth, with simultaneous deterioration of the 
hearing acuity. There are also headache, lassitude, and moderate 
rise of temperature. The manifestations continue with unabated vigor 
for two or three days, during which there are repeated paroxysms of 
vertigo. At the climax of the disease there may be spontaneous nystag- 
mus toward the non-affected side and transitory deafness. The viru- 
lence of the symptoms, however, will not last long. The nystagmus is 
presently directed again toward the affected side, then becomes bilateral, 



AFFECTIONS OF THE INTERNAL EAR 265 

and the hearing acuity re-establishes itself. All symptoms will have 
disappeared in about a week, and recovery takes place in nearly all 
cases with restitution of the reflex excitability of the static labyrinth. 
If the cochlea was intact previous to the onset of the affection, fairly 
good hearing will be re-established. Should, however, the cochlea and 
Corti's organ have undergone degenerative changes due to a preceding 
chronic suppuration of the middle ear, there is danger of the labyrin- 
thitis being followed by permanent, insidiously developing deafness. 

Treatment is purely symptomatic. During the violent irritative 
manifestations, rest in bed in a dark room, lying on the healthy side, is 
indicated. Usually a patient finds out himself in which position of the 
body and head he is least molested by vertigo and in which his nystag- 
mus is least. 

The diet should consist of small quantities of fluid, easily digested 
food. Violent attacks of vertigo may be relieved by the galvanic cur- 
rent (2-6 ma.), the current being conducted transversely through the 
head; 5 or 6 applications daily of from 2 to 5 minutes' duration. Sodium 
veronal (0.5-1.0), which has also been recommended in sea-sickness, 
may relieve the attack. In long-continued violent vertigo nothing but 
subcutaneous injection of morphine gives relief. 

3. CIRCUMSCRIBED AND DIFFUSE UNCOMPLICATED (SIMPLE) SUPPURA- 
TION OF THE LABYRINTH 

Etiology. — It may be said in a general way that only middle-ear 
suppuration which takes a grave course will lead to suppuration of the 
labyrinth. In acute or chronic middle-ear suppuration there is either 
otitis of the epitympanic type to deal with, or antrum suppuration with 
long-existing retention of pus, or severe middle-ear suppuration occur- 
ring in the course of scarlet fever or measles. In chronic cases there are 
usually neglected, highly fetid pus foci in the middle ear, which have 
long previously involved the bone or led to the formation of a choles- 
teatoma. 

Symptoms. — There are frequent earaches and headaches. The pus 
secretion from the external auditory meatus varies, being sometimes 
abundant, sometimes slight, sometimes absent altogether. The laby- 
rinth symptoms set in either without warning or after prodromal signs. 
The latter include headache, indistinct feeling of vertigo, lassitude, 
sensation of heaviness in the head or ear, involuntary twitching of the 
muscles supplied by the facial nerve on the affected side, or facial paraly- 
sis. Sometimes there are subjective noises in the form of a screeching, 
very high whistling sound. The typical sign of suppurative inflamma- 
tion of the cochlea consists in a more or less sudden onset of deafness. 
If the patient has previously had fairly good hearing, the symptom of 



266 THE DISEASES OF CHILDREN 

deafness is distinct, especially if the affected ear has been the better 
one; but in chronic cases of middle-ear suppuration the hearing ability 
has already been bad before or been present only in remnants. The 
extinction of such remnants, which means the establishment of complete 
deafness, may entirely escape the patient's attention, especially when 
the other ear has normal or good hearing function. 

In a few cases of chronic middle-ear suppuration, degenerative 
changes of the cochlea and Corti's organ may lead to deafness in the 
course of years. In any cases of this kind where deafness has occurred 
long ago, the onset of suppurative inflammation in the region of the 
cochlea will often occur without any symptoms. 

The suppurative inflammation of the static labyrinth (vestibulum, 
semicircular canals) is associated with violent rotatory vertigo and equi- 
librial disturbances. Should there be a sudden diffuse suppuration of 
the labyrinth with a hyperacute course, in which the entire sensory 
epithelium is immediately destroyed, there will be only one, but very 
violent attack of rotatory vertigo. The attack is always described cor- 
rectly by the patient, and, owing to the violence of the attack, he will 
usually be able to indicate the direction in which the rotation occurred. 
The rotation is usually passive, — a rotation of the surroundings; less 
often an apparent rotation of the patient's own body. (An apparent 
rotation of the surrounding objects to the right corresponds to an 
apparent rotation of the patient's own body to the left.) 

The attack of vertigo is associated with violent nystagmus due to 
the labyrinth. The direction of the apparent rotation of the surround- 
ing objects usually corresponds to the direction of the nystagmus. If, 
therefore, a patient states having had the perception of objects around 
him turning to the right, it is always equivalent to the presence of a 
right nystagmus, being directed toward the same side. The sensation of 
an apparent rotation of the patient's own body to the right, however, is 
usually associated with the presence of a labyrinth nystagmus toward 
the left. 

Nystagmus and vertigo are often present during the early stage of 
a suppuration of the labyrinth. The nystagmus is not intense and, 
therefore, only demonstrable with lateral vision. At the same time 
spontaneous bilateral nystagmus toward the affected side may be ob- 
served, and, besides, the kind of nystagmus may alternate. If there is 
vertigo, there will be spontaneous nystagmus toward the affected side, 
while during the periods when there is no vertigo there is either bilateral 
nystagmus or none at all. 

The increase of vertigo which indicates the onset of diffuse suppu- 
ration of the labyrinth is always accompanied by violent spontaneous 
nystagmus of the greatest possible intensity toward the healthy side. 



AFFECTIONS OF THE INTERNAL EAR 267 

It is most pronounced with vision toward the side of the nystagmus, 
which means toward the healthy side, but it will also persist with straight 
vision, even with vision toward the affected side. The patient exhibits 
the signs of a marked subjective or objective rotatory vertigo. If the 
paroxysm seizes him at home, he will instantly go to bed, or lie down 
prone on the floor, remaining in this position until somebody comes to 
his aid to put him to bed. If the paroxysm seizes him in the street, he 
is exposed to the most severe accidents. 

A few years ago a patient was taken to the hospital by the First- 
aid Society, with the following report : The patient suffered from chronic 
suppuration of the middle ear, and had a few weeks previously com- 
plained of periodical, unimportant vertigo. On the day of admission he 
went to work in the morning, and in the street was overcome by a violent 
paroxysm. He was only just able to clutch a lamp-post, to which he 
held spastically until he was rescued by an officer of the First-aid Society 
and placed on a stretcher. 

Concomitant manifestations of such a violent paroxysm are equi- 
libria! disturbances and repeated vomiting. The equilibria! disturbances 
occur in conjunction with the signs of objective vertigo, and find expres- 
sion in considerable staggering, positive Romberg's symptom, inability 
to stand on one leg with closed eyes, and in disturbances when walking 
forward or backward with closed eyes. Should there be a very high 
degree of vertigo, there can be no question of standing or walking; the 
patient may even be unable to sit up in bed. While in bed he will in- 
stinctively find the best position for body and head, in which the nystag- 
mus is least. In that position he will feel the vertigo less than in any 
other. It will invariably be observed that patients with suppuration of 
the labyrinth and nystagmus toward the healthy side lie on the affected 
side, or at least turn the head in that direction. Having at last found the 
most comfortable position, the patient will be compelled to relinquish it 
frequently by repeated vomiting. During an attack lasting for two or 
three hours, the patient may have to vomit 20 or 30 times; in any case 
there is always nausea during the entire duration of the attack, the 
patient being unable to retain even the slightest quantities of fluid. 

The acute stage of the first attack is followed by a more or less con- 
tinuous sensation of vertigo. Without being quite free from giddiness, 
its intensity is considerably diminished, vomiting has ceased, and the 
sensation of rotation now exists only with vision toward the healthy side, 
as long as the nystagmus prevails. He can retain food, after a few days 
he can sit up in bed without being particularly bothered by vertigo, and 
after from 8 to 14 days the latter has completely disappeared. Examina- 
tion of the internal ear will then reveal total deafness and absence of 
excitability of the vestibulum and the semicircular canals. If the sensory 



268 THE DISEASES OF CHILDREN 

epithelium has not been completely destroyed at the beginning of the 
suppuration of the labyrinth, some hearing remnants and reflex excita- 
bility of the static labyrinth will, at first, still be retained. In these cases 
there is nystagmus toward the affected side at the first attack of vertigo. 
These cases, which belong to the class of circumscribed suppurations of 
the labyrinth, sometimes recover at this stage of the affection, retaining 
at first some hearing remnants and excitability of the semicircular canals. 
Should the suppuration make further headway, there will be renewed 
accessions of vertigo, the last of which will be characterized by nystagmus 
toward the healthy side and terminate with complete destruction of the 
labyrinth, which means deafness and absence of excitability of the semi- 
circular canals. 

Uncomplicated suppuration of the labyrinth is not accompanied by 
any local cerebral symptoms. The fundus of the eye and the cerebro- 
spinal fluid are normal. The temperature in acute suppuration of the 
labyrinth is moderately raised. There are no unilateral disturbances of 
coordination. The reflexes, superficial and deep sensitiveness are normal. 

Diagnosis. — The diagnosis of suppuration of the labyrinth is easily 
made when in a case of middle-ear suppuration or suppurative menin- 
gitis there are accessions of rotatory vertigo and sudden deafness. The 
diagnosis becomes more difficult the less abrupt the labyrinth symptoms 
occurred and the longer the symptoms have existed without leading to 
complete loss of function of the internal ear. 

In circumscribed suppuration of the labyrinth the history will reveal 
attacks of vertigo, while examination will show that part of the labyrinth 
is still functioning and the rest has lost its function. There may, for 
instance, be positive hearing, although the excitability of the semicircular 
canals is extinct and there is permanent diminution of the equilibrium. 
The diagnosis is more difficult in cases of circumscribed suppuration of 
the labyrinth, where nothing but the acoustic apparatus has been de- 
stroyed while the semicircular canals have retained their function. The 
diagnosis can then be made if the history establishes the fact that deaf- 
ness has occurred in an apoplectiform manner. 

As to diffuse, uncomplicated suppuration of the labyrinth, there 
can be no difficulty in making the diagnosis with attentive observation 
of the patient and sufficient experience in the interpretation of spontane- 
ous nystagmus, although the preceding attacks of vertigo which have 
been established by the history do occur in other affections of the laby- 
rinth as well. Of particular value from an anamnestic and diagnostic 
point of view, however, is the isolated violent attack of vertigo, under 
which Stage II has developed into Stage III, together with the occur- 
rence of deafness. 

As to the differential diagnosis, the following affections have to be 



AFFECTIONS OF THE INTERNAL EAR 269 

considered: (1) serous labyrinthitis; (2) hemorrhage of the labyrinth; 

(3) acute serous inflammations of the labyrinth (neurolabyrinthitis) and 
acute degenerations of the labyrinth in cases of typhoid and syphilis; 

(4) traumatic injury to the labyrinth (fracture) ; (5) neurasthenia of the 
labyrinth. 

Differentiation between diffuse suppuration and serous labyrinthitis 
is rendered possible by the fact that in the latter the stage of inflam- 
matory paralysis is not reached at all or only for a short time and, 
instead of Stage IV following, there is return to Stage II and later to 
Stage I, with restitution of the excitability according to the course of 
the healing process of the serous labyrinth. 

Apoplectiform non-traumatic hemorrhages of the labyrinth are 
nearly always associated with lymphomatous affections of the blood. 
The labyrinth, which previously was normal, is completely destroyed 
by an effusion of blood. The differential diagnosis can at once be estab- 
lished by the blood findings of leukaemia, and, besides, there are slight 
attacks of vertigo in diffuse suppuration of the labyrinth preceding the 
violent paroxysm, whereas in cases of hemorrhage of the labyrinth there 
have never been any such attacks before. The paroxysm in hemorrhage 
of the labyrinth is exceedingly violent, but of considerably shorter dura- 
tion than in suppuration of the labyrinth. Furthermore, the chronic 
vertigo which follows the acute attack in suppuration of the labyrinth 
is more or less absent in hemorrhage of the labyrinth. 

In syphilis of the labyrinth or acute degeneration in typhoid the 
isolated violent paroxysm of vertigo is preceded by a very large number 
of lighter attacks. 

The differentiation from trauma of the labyrinth can be made from 
the history regarding the trauma itself. This is supported by symptoms 
of other cerebral nerves (trochlearis, abducens, facialis). Besides, it is 
important to remember for the diagnosis of suppuration of the labyrinth 
that an existing previous suppuration of the middle ear or an intracranial 
suppuration must be established. 

Treatment. — Many uncomplicated cases of empyema of the laby- 
rinth recover spontaneously. Rest in bed is urgently needed from the 
onset of the affection, and may have to be continued for many weeks, 
until the symptoms have completely subsided. During the period of 
violent attacks it is advisable to darken the room and to bring patient 
into a position where his nystagmus is felt least. Most patients instinc- 
tively find that position themselves. 

The diet must be selected with the utmost care. Small quantities 
of fluids are administered by the spoonful, without changing the patient's 
position if possible. Stimulating beverages, such as alcohol, are rigor- 
ously excluded. 



270 THE DISEASES OF CHILDREN 

As to galvanization, etc., see p. 265. Subcutaneous morphine 
injections may be necessary in the violent attacks. 

Diffuse suppuration of the labyrinth which has originated from 
meningitis may recover spontaneously under this treatment; the otitic 
form, however, will only so recover if the osseous capsule of the labyrinth 
has remained intact. Should the osseous region between the membranous 
labyrinth and the middle ear be affected, resection of the labyrinth will 
be necessary. 

4. COMPLICATED DIFFUSE SUPPURATION OF THE LABYRINTH 

Complicated diffuse suppuration of the labyrinth is the result of 
the inflammation involving the anatomical region of the labyrinth either 
by direct spreading or by metastasis. Accordingly, there are to be dis- 
tinguished endocranial and extracranial diffuse suppurations of the 
labyrinth. 

(a) Suppuration of the Labyrinth Complicated by Extracranial Involvement 

This group comprises the diffuse suppurations of the labyrinth in 
the course of which suppurative osteitis of the petrous bone, fistula for- 
mation at the lateral wall of the labyrinth with sequestration of that 
wall, or paralysis of the facial nerve have developed. 

Anatomy. — In diffuse suppuration of the labyrinth the involvement 
of the lateral wall is usually a deuteropathic manifestation or the termina- 
tion of a labyrinth suppuration. Under the influence of chronic middle- 
ear suppuration, there will be sequestration of flat, minute particles of 
the lateral labyrinth wall, particularly at the promontory; more fre- 
quently, however, carious destruction and fistula formation consequent 
upon pus breaking through from the labyrinth toward the middle ear. 
The fistula either develops over preformed anatomical tracts (vestibular 
and cochlear windows), or else the bone will be destroyed at those places 
where the capsule of the labyrinth is normally thin (eminence of the 
lateral semicircular canal, promontory). In the presence of multiple 
fistulse the entire wall of the labyrinth may be sequestered. This is 
followed by exfoliation of the osseous parts situated in the labyrinth 
itself (modiolus, lamina spiralis, crista vestibuli) ; in the end, sequestra- 
tion of the entire petrous bone may occur, especially in tuberculous 
cases. 

Should the suppurative inflammation of the bone reach the facial 
nerve, there will be suppurative infiltration of the nerve-sheaths and 
finally of the nerve itself. A cholesteatoma of the labyrinth, if present, 
may completely destroy the facial nerve, enabling the pus to spread 
either along the facial canal into the endocranium or peripherally toward 
the base of the petrous bone. 



AFFECTIONS OF THE INTERNAL EAR 271 

Symptoms. — Suppurative osteitis may exist for a long time without 
giving rise to any symptoms if the entire labyrinth has been destroyed 
by diffuse suppuration. 

An objective sign of the affection of the lateral wall of the labyrinth 
capsule consists in the otoscopic demonstration of sequestered bones, 
in the spontaneous expulsion of minute sequestra, and in the demonstra- 
tion of labyrinth fistulae. The pus of the middle ear is fetid in the highest 
degree; the quantity of the secretion varies, and there may be no secre- 
tion at all for days together. 

The otoscopic demonstration of a fistula or sequestrum is possible 
only in exceptional cases, while the expulsion of sequestra is more fre- 
quently observed. Patients sometimes preserve these, and, upon careful 
examination, they are found to be parts of the capsule or interior of the 
labyrinth. Labyrinthogenic paralysis of the facial nerve is a positive 
but often very unfavorable symptom. The paralysis sets in insidiously. 
Prodromal signs in the shape of involuntary twitching of the mimic 
musculature and transient paralysis of some group of muscles may last 
for one or two weeks, and it is only then that permanent paralyses will 
set in and continue to develop until, in the end, the picture of a complete 
peripheral unilateral paralysis presents itself. This is explained by the 
fact that the suppuration spreads to the facial nerve in a gradual way, 
involving first the peripheral bundles of the nerve and later the fibres 
which are axially situated in the trunk. Temperature is usually some- 
what raised. 

Course and Treatment. — Spontaneous recovery without operation 
may occur in exceptional cases; otherwise endocranial labyrinth fistulae, 
meningitis, cerebellar abscess, or caries of the petrous bone will develop, 
while the fetid suppuration continues. Consequently, nothing but opera- 
tion will afford radical treatment, and this consists in the exposure of 
the middle-ear spaces and resection of the labyrinth. The latter has to 
be preceded by exposure of the dura of the middle and superior cranial 
fossae. 

Labyrinth Operation. — Complete evacuation of the mastoid process is 
a necessary preliminary step. Then the dura of the posterior and medial 
cranial fossae is dissected free, and the two apertures thus obtained are 
united by removing the superior edge of the pyramid. The dura hav- 
ing been carefully mobilized, the labyrinth is exposed step by step in 
the direction of the affected bone. Commencing at the semicircular 
canals, the petrous bone is removed with the chisel, starting from the 
exposed posterior fossa. 

Spontaneous evacuation of the cerebrospinal fluid from the laby- 
rinth spaces is a sure sign of the affected parts having been sufficiently 
drained. This evacuation can be attained in all acute cases. In older 



272 THE DISEASES OF CHILDREN 

cases it may be rendered impossible by the accumulation of blood coagula 
in the labyrinth spaces, by pathological connective tissue or new-formed 
bone. A cholesteatoma may likewise prevent the evacuation after resec- 
tion of the labyrinth. In these cases the vestibulum has to be opened 
after removing the semicircular canals. In all cases, however, the 
cochlea must be opened by cutting away the promontory. If labyrinth 
fluid flows out of the cochlea, the operation may be stopped. Should 
the cochlea, however, contain pus or a cholesteatoma, it will have to be 
emptied with a sharp spoon. 

The wound is loosely tamponed with iodoform or isoform wicks; 
one bundle of wicks is conducted to the cochlea and outward through 
the external auditory meatus, and a second bundle toward the vestibu- 
lum or the semicircular canals (which have been opened) and conducted 
outward through the retro-auricular wound. The latter is left open and 
should only be closed by suture at the end of the first week if the healing 
process takes a favorable course. 

The prognosis of diffuse suppuration of the labyrinth without intra- 
cranial involvement is not unfavorable if the operation has been done in 
proper time. Recovery will usually take much longer than that of an 
ordinary radical operation. It occurs under formation of a resistant 
layer of cicatricial tissue which completely covers the petrous bone, 
leaving a spheric cavity, invested with glistening gray epidermis. 

The prognosis of paralysis of the facial nerve is dependent upon the 
electric excitability of the nerve and on the local changes found at opera- 
tion (see chapter on Paralysis of the Facialis.) 

The subjective condition of the operated patients is good in most 
cases, but they should abstain from any strenuous work even after com- 
plete recovery. There remains a tendency to rapid fatigue for months 
afterward, and headache will easily occur upon great mental or physical 
exertion. Neurotic patients may experience neurasthenic complaints 
even after an ideal healing process, which may simulate an endocranial 
complication or the continuance of an inflammatory affection of the 
labyrinth. 

(b) Diffuse Suppuration of the Labyrinth Complicated by Endocranial 

Involvement 

Under this head all those cases are summarized in which a diffuse 
suppuration of the labyrinth has led to a suppurative inflammation of the 
endocranium either by direct spreading or by metastasis. 

Anatomy. — Direct spreading of the pus from the labyrinth to the 
endocranium leads to destruction of that part of the labyrinth capsule 
which is situated between the labyrinth and the cranial fossae, to destruc- 
tion of the petrous bone, and to the formation of one or more endo- 



AFFECTIONS OF THE INTERNAL EAR 273 

cranial fistulae. The fistula either takes its way through preformed canals 
(internal auditory canal, cochlear or vestibular aqueduct, superior semi- 
circular canal, fossa subarcuata), or it develops, like an extracranial 
fistula, where the osseous layer between the spaces of the labyrinth and 
the dura is particularly thin (superior semicircular canal, commissure of 
the semicircular canals, sinus half of the posterior semicircular canal). 
Involvement of the posterior cranial fossa is far more frequent in endo- 
cranial complications than involvement of the middle cranial fossa. 

Should the suppuration spread through the internal auditory canal 
over the cochlear aqueduct, pachyleptomeningitis will develop. In all 
other cases there will at first occur a pachymeningitis externa, in the 
wake of which an extradural or cerebellar abscess will develop. 

Spreading of the suppuration over the vestibular aqueduct and the 
endolymphatic duct may result in an extradural abscess at the external 
aperture of the vestibular aqueduct or a saccus empyema. 

Metastatic spreading of the labyrinth suppuration may lead to 
suppurative meningitis or cerebellar abscess with or without involvement 
of the interpolated layers. 

Suppurative sinus phlebitis is only rarely caused by suppuration of 
the labyrinth; at least it is only exceptionally possible to prove that in 
these cases the sinus thrombosis has been caused by the suppuration of 
the labyrinth and not by the underlying cause, the chronic middle-ear 
suppuration. Thus, fistula? of the upper semicircular canal may lead to 
infection of the sinus petrosus superior and thence to suppurative phle- 
bitis and pyaemia. Saccus empyema and labyrinthogenic extradural 
abscesses of the hindmost region of the posterior cranial fossa may be 
followed by suppurative inflammation and thrombosis of the sigmoid 
sinus. 

Symptoms and Course. — Tormenting headache usually occurs with- 
out any warning as soon as the suppuration of the labyrinth has reached 
the dura. The headache usually occurs in the vertical region if the dura 
of the middle cranial fossa has been affected ; the pain will be at the occi- 
put or base of the skull if the dura is affected at the posterior surface of 
the petrous bone. In the latter case patients will avoid any sudden 
movement of the head. Active movements of the head are in many 
cases considerably restricted, while, according to the most careful investi- 
gations, the passive movements are fully maintained. Accordingly, 
there is moderate stiffness of the neck and often abnormal inclination 
and torsion of the head toward the affected side. 

At the time that diffuse suppuration of the labyrinth is in active 
operation, irritative manifestations of the labyrinth are usually no longer 
present, and their former occurrence can therefore only be established 
by the history. Vertigo, equilibrial disturbances of any importance, 

VI— 18 



274 THE DISEASES OF CHILDREN 

and vomiting now occur only on mechanical irritation or by suppurative 
inflammation of the eighth nerve in cases where the suppuration has 
spread to the endocranium along the nerve-bundle of the internal audi- 
tory canal. In these cases it is even possible for a new positive fistular 
symptom to be elicited from time to time if any extracranial fistulse exist. 
Examination of the ocular fundus often reveals abnormal venous plethora 
and sometimes optic neuritis at the affected side. Spreading of the 
suppurative process to the pyramid of the petrous bone will be followed 
by abducens paresis, or complete abducens paralysis with double vision. 
Temperature is moderately raised; usually there is anorexia and some- 
times vomiting. There are depression, dislike of work, and a desire to 
rest in bed. Lumbar puncture, even in the early stage, yields a turbid 
fluid in many of these cases. The evacuated fluid will, on standing, form 
slight coagula, which microscopically show abundant mono- and poly- 
nuclear leucocytes, and often micro-organisms (staphylococci, strepto- 
cocci, etc.). In many of these cases where the findings as to micro- 
organisms are positive, cultures and animal tests will prove negative, 
but change to positive as the affection makes further progress. Should 
the suppuration lead to the formation of a cerebellar abscess, the corre- 
sponding symptoms will now make their appearance. A detailed de- 
scription of the same is contained in the section on Cerebellar Abscesses. 

Diagnosis. — Should headache, rise of temperature, or impaired move- 
ments of the head persist, after the paroxysms of vertigo and the mani- 
festations of intense labyrinth nystagmus have abated, it is safe to assume 
an endocranial involvement induced by the labyrinth. 

The diagnosis is more difficult when at the time of endocranial 
involvement the manifestations on the part of the labyrinth have not 
yet disappeared, particularly when the patient still complains of vertigo. 

A differentiation is impossible if the suppuration has spread to the 
eighth nerve in the internal auditory canal, as the inflammatory processes 
of the formerly non-affected nerve may cause similar manifestations as 
those of a fresh suppuration of the labyrinth. In such cases the diagnosis 
may be rendered possible by the complaints continuing after resection 
of the labyrinth or their recommencing after a slight interval. However, 
by strict adherence to the rule to precede every resection of the labyrinth 
by exposure of the dura, the endocranial complication will be determined 
at the operation, should it not have been possible to recognize it clinically. 

Treatment. — Early operation offers the only chance of recovery. 
This consists in opening the middle-ear spaces, in the free exposure of 
the posterior and medial cranial fossae, removal of the superior edge of 
the petrous bone, and resection of the ear labyrinth. In the presence of 
suppurative inflammatory changes of the nerve-trunk, it is necessary to 
expose the internal auditory canal by removal of the lateral osseous wall 



AFFECTIONS OF THE INTERNAL EAR 275 

which is situated between the vestibulum and the auditory canal. After 
this the dural lining of the internal auditory canal is incised. This form 
of resection, together with removing the cochlea, will expose the intra- 
dural space of the posterior cranial fossa at the internal auditory canal. 
It now communicates with the middle-ear spaces through the internal 
auditory canal and the cochlear aqueduct. It is advisable to incise the 
dura of the posterior cranial fossa in the region of the resection, because 
it is just these small incisions which invite the danger of direct migration 
of pathogenic germs into the cranial cavity. 

Should the cerebellum be unchanged, there will be no prolapse of 
the bone. In the presence of encephalitis, the cedematous cerebellum 
will protrude into the incision. In these cases there may be persistent 
cerebellar prolapse, which may later be remedied by skin plastic opera- 
tions. Sometimes the prolapsed portion becomes necrotic and sloughs off, 
with consequent healing, but there may also occur an intrameningeal 
abscess in the shape of large accumulations of pus at the fundus of the 
posterior cranial fossa. 

In such cases the sudden onset of a fulminating, diffuse suppurative 
meningitis, many weeks after the operation, may lead to death within 
a few days, in spite of the apparently favorable course. 

In cases which take a favorable course, the healing process does not 
differ from that in ordinary resections of the labyrinth. The occasional 
expulsion of small sequestra will not permanently disturb the healing 
process. 

A compilation of the cases of suppuration of the labyrinth with 
endocranial complications which have been operated upon in my depart- 
ment shows a mortality of about 20 per cent., including the cases of 
labyrinthogenic cerebellar abscesses. The prognosis of labyrinthogenic 
suppurative pachyleptomeningitis, when restricted to the posterior cranial 
fossa, is relatively favorable, although the fact may seem remarkable. 



XII. EXTRACRANIAL AFFECTIONS OF THE EAR 

Extracranial affections of the ear occur by a middle-ear suppuration 
leaving the region of the middle ear and advancing into the surrounding 
territory except toward the cranial cavity. 

Accordingly, we distinguish: 

(1) Subperiosteal mastoid abscess. 

(2) Perforating abscess toward the squama of the temporal bone 
and the zygomatic process. 

(3) Perforation to the external auditory canal from the fistulse of 
that canal. 

(4) Descent of pus toward the submaxillary bone, sometimes with 
periarticular suppuration into the submaxillary articulation. 

(5) Descent of pus along the tube. 

(6) Descending abscesses of the neck: (a) perforation of mastoid 
abscess through the pyramid, (b) through the middle wall of the mastoid. 

It is in the nature of the anatomical structure of the temporal bone 
that all the variations above enumerated result in most cases from the 
direct extension of spreading of pus. There is, consequently, an imme- 
diate anatomical communication between the pus focus of the middle 
ear and the extracranial focus. The smaller part of extracranial com- 
plications are caused by metastatic suppuration or by phlegmonous 
inflammation originating in the ear. 

I. SUBPERIOSTEAL MASTOID ABSCESS 

A subperiosteal mastoid abscess is occasioned by an accumulation 
of pus between the periosteum and the lateral wall of the mastoid process. 
It occurs in the course of a suppurative inflammation of the mastoid 
process if the abscess in the bone finally perforates outward through an 
osseous fistula underneath the periosteum. The fistula is usually situated 
in the mastoid fossa, near the antrum in the upper part of the mastoid 
process. In fistulse of the posterosuperior wall of the auditory canal the 
pus may gradually lift up the soft parts of the osseous auditory duct, 
force a way underneath the periosteum, and finally collect in an abscess 
above the mastoid process. Metastatic subperiosteal mastoid abscesses 
without any mastoid fistulse are rare in infancy and childhood, and the 
same is true of subperiosteal mastoid abscesses in simple suppuration of 
the middle ear without any distinct clinical sign of the mastoid being 
involved in the inflammation. In such cases the metastasis occurs 
through the small veins of the soft covers of the mastoid which extend 
into the middle ear. Fistulse which are situated below the level of the 

276 



EXTRACRANIAL AFFECTIONS OF THE EAR 277 

insertion of the sternocleidomastoid muscle lead to descending abscesses 
of the neck, and no longer to periosteal abscesses (Figs. 101, 102). 

Subperiosteal mastoid abscesses occur oftener in acute suppurative 
mastoiditis than in the chronic form. They occur early in a diploic 
abscess when the cortex is thin. Their occurrence is particularly 
rapid in mastoiditis of children under four years of age. Here the bone 
is exceedingly vascular, the cortical layer thin, the mastoid largely or 
entirely diploic. Besides, the infantile lateral wall of the antrum is 
thin and often still cartilaginous in parts. In rhachitic bony changes, 
which are of frequent occurrence, the resistance of the cortical layer to 
the invading pus is still more reduced and the bone is rapidly destroyed. 
Under these circumstances it is not surprising that, as early as a few 
hours after the occurrence of mastoid manifestations, in infancy, a 
subperiosteal perforation and fluctuation have occurred. Where the 
cortical layer is thick, however, perforation will not occur before the 
lapse of four or five weeks. 

Subperiosteal abscess is rare in chronic middle-ear inflammation. 
This is explained by the fact that in the course of the latter there occurs 
a gradual thickening and partial sclerosis of the osseous structure of the 
mastoid process without any acute inflammatory manifestations. This 
will in most cases effectually check a spreading of the suppuration to 
the mastoid and prevent a perforation through the lateral surface of 
the same. To allow the suppuration to spread to the mastoid, a fresh 
acute attack of the chronic suppuration or an acute suppurative decom- 
position of a cholesteatoma of the middle ear is at least required. The 
latter is the more frequent occurrence. 

In these cases, however, the subperiosteal abscess is rarely the only 
otitic involvement. More frequently it is merely a part manifestation 
of an endocranial complication caused by the rekindling of a chronic 
suppuration or by the acute suppurative decomposition of a cholestea- 
toma. In subacute purulent mastoiditis a subperiosteal mastoid abscess 
is often the sign of an impending mobilization of a sequestrum. 

Anatomy. — It occurs only in cases of tuberculous subperiosteal 
abscess that there is an accumulation of pus within closed walls without 
reaction. In all other cases the middle wall of the abscess, — i.e., the 
lateral wall of the mastoid, — as well as the lateral wall of the abscess, 
presents more or less important inflammatory changes. The fistulse 
found in the cortical layer have already been mentioned. They are 
sometimes canals with such narrow lumina as to be passable only by a 
small sound or a blunt needle. They may, however, attain the size of a 
goose-quill, ending in a large aperture, which gives at first sight the 
appearance of total destruction of the cortical layer of the mastoid, of a 
broad communication between the endomastoid and subperiosteal pus 



278 THE DISEASES OF CHILDREN 

foci, and a confluence of both abscesses into one. Sometimes there are 
several fistulse, which may cause a cribriform perforation of the bone in 
the presence of a thin but resistant cortical layer. The fistula is gradually 
filled with granulations as the abscess continues its existence, while the 
lateral surface of the mastoid process is relatively seldom the seat of 
granulations. The soft layers over the abscess are usually thickened by 
calosities which may attain a thickness of Yi to 1 cm. in advanced cases. 
These growths generally occur by fibrinous deposits between the perios- 
teal layers as well as between the periosteum and the subcutaneous 
cell tissue. The fibrin may become organized, leading to sclerosis of the 
connective tissue. The periosteal wall facing the abscess is usually 
covered with granulations. Its injected and strongly osmotic condition 
sharply demarcates it against the periosteum of the normal surroundings. 

As soon as the abscess is about to perforate, there occur infiltra- 
tion, reddening, and swelling of the skin; finally the skin assumes a 
livid hue in one or more places, and by destruction of a circumscribed 
area a retro-auricular fistula will be formed, through which the abscess 
pus and that of the mastoid process are evacuated. The skin fistula is 
in most cases situated on the level of the osseous fistula of the mastoid 
process, so that a probe introduced into the skin fistula will penetrate 
into the interior of the mastoid without meeting with any resistance. 

The size of subperiosteal abscesses varies from a pea to a man's 
hand. This extraordinary enlargement is occasioned by the pus gradually 
lifting the periosteum beyond the area of the temporal bone. It usually 
penetrates first the squama of the temporal bone, then the occipital bone, 
the zygomatic process, and finally the parietal bone. Spreading beyond 
the vertex to the parietal bone of the other side occurs only in rare cases. 

I have observed three cases where the fluctuation was demonstrable 
from the central part of the mastoid region backward to the nape, thence 
forward to the zygomatic process, and upward to the parietal bone of 
the other side, thus crossing the vertex. 

Fetid pus is found only in cases of chronic middle-ear suppuration, 
and is usually a part manifestation of an intracranial complication, the 
most frequent of which is a sinus thrombosis. 

Subperiosteal gas abscesses are very rare and occur only in cases 
of chronic middle-ear suppuration with endocranial complications. 

Symptoms. — The local findings are furnished by the abscess itself. 
In the mastoid region there is a swelling in the shape of a flattened globe, 
the skin of which is drawn tight over it and often becomes hypersemic and 
lividly discolored upon impending perforation. The more or less per- 
ceptible fluctuation depends upon the size of the abscess and upon the 
extent to which the subcutaneous cell tissue has been destroyed. Spon- 
taneous tenderness of the mastoid is rare in these cases; it may be en- 



EXTRACRANIAL AFFECTIONS OF THE EAR 



279 



tirely absent, and principally depends upon the tension of the abscess 
wall. Abscesses with scant contents do not cause spontaneous pain, 
but there is a more or less pronounced degree of pain on pressure. The 
purulent contents can be easily seen by transillumination and comparison 
with the other side. The concha stands away from the head, sits lower 
than its mate, and has a forward and downward torsion (Fig. 96). 

The tympanic changes agree in most cases with those in acute 
mastoiditis. Sometimes, however, the local inflammatory manifestations 
have entirely subsided, so that both tympanic membrane and hearing 
acuity are quite normal. Testing, however, the bone-conduction over 
the abscess, considerable reduction will be found, which is due to the 
fact that the abscess (fluids and bad sound conductors) is interposed 
between the foot of the tuning-fork and the osseous surface. The tem- 
perature of the patient is moderately elevated. There are neither cere- 
bral symptoms nor general manifestations. Often there are complaints 



Fig. 96. 




Pathognomonic change of position of the right concha in right-sided subperiosteal mastoid abscess. The change 
of position is best observed in the dorsal aspect. 

of tormenting, knocking, subjective noises and pulsation in the region 
of the affected ear. Sometimes there is a widely diffused cedema of the 
face, with occlusion of the lid fissure and swelling of the cheek. In these 
cases mastication is likewise impaired. 

Diagnosis. — There can be no diagnostic difficulty in view of the 
objective abscess symptoms. The history, otoscopic findings, and the 
characteristic position of the concha distinctly betray the otitic character 
of the abscess. 

In the presence of a subperiosteal mastoid abscess it is of the greatest 
importance not to overlook any intracranial otitic affection that may be 
present. It has already been stated that subperiosteal abscesses in 
chronic middle-ear suppuration nearly always represent a part manifes- 
tation of an endocranial complication. 

In acute cases the above symptoms will be all to go by, remember- 
ing, however, that a subperiosteal mastoid abscess is not accompanied by 



280 THE DISEASES OF CHILDREN 

serious local or general manifestations. Should such be present, therefore, 
— such as headache, delirium, convulsions, high temperature, intermittent 
fever, chills, icterus, — we must not be content with the diagnosis of sub- 
periosteal mastoid abscess, but must look for an endocranial affection. 

In making a differential diagnosis subperiosteal abscesses of non- 
otogenic origin, which have spread secondarily to the mastoid region, 
should be considered first. These are nearly always cases of tuberculous 
osteoperiostitis of the zygomatic process or squama of the temporal 
bone, in very rare cases of the occipital bone. The history is to be taken 
as the first guide (absence of a previously existing middle-ear inflamma- 
tion), also the development of the disease (no middle-ear symptoms, 
fever, or pain) . A careful examination of the patient, and especially the 
operative findings, will permit of determining which was the bone pri- 
marily affected. 

Glandular abscesses and bundles situated at the musculus splenius 
capitis may simulate mastoid abscesses, especially if the patient has also 
middle-ear symptoms or the history reports such symptoms. Exami- 
nation will generally, however, show that the abscess does not extend 
beyond the posterior half of the mastoid process and will not reach to the 
frontal part, but terminate sharply demarcated at the mastoid process 
itself. The concha is in normal position, the mastoid pyramid is dis- 
tinctly palpable, and the external auditory canal is unchanged. In 
doubtful cases the decision must depend upon the operative findings. 
The middle wall of a subperiosteal abscess is always formed by exposed 
bone, while the middle wall of a glandular abscess is covered with callous 
connective tissue or remnants of the glandular covers, and the periosteum 
is intact. 

Furunculosis of the auditory canal may in rare cases lead to descent 
toward the mastoid process, even to abscess formation. The diagnosis 
in these cases is easy, and, besides, the operative findings (periosteum 
unchanged, pus between the skin and periosteum, no subperiosteal pus) 
will guard against error. In tuberculous perichondritis descent toward 
the mastoid process may be caused by extensive cartilaginous necrosis. 
The abscess is situated on the level of the apex of the mastoid and 
usually extends forward to the middle surface of the lobulus. The abscess 
shows all the signs of a tuberculous ulceration. 

The differential diagnosis has still to take into consideration sub- 
periosteal hsematoma in fractures of the base of the skull which pass 
through the mastoid process. History and transillumination (dark-red 
diaphany) will enable us to recognize the haematoma as such. In some 
cases, however, suppuration of the hsematoma may develop later. Should 
there be grave cerebral manifestations aside from the fracture, a clinical 
differentiation will be impossible, but at operation, after evacuation of 



EXTRACRANIAL AFFECTIONS OF THE EAR 281 

the abscess and after exposure of the mastoid process, the fissure of the 
fracture, filled with blood and pus, will be recognized. 

The diagnosis of actinomycotic abscesses will be made from the 
microscopic findings of the fungi. 

Treatment. — OEdematous swelling of the soft covers of the mastoid 
often recedes spontaneously or under conservative treatment, especially 
in children. Generally speaking, however, the treatment of subperiosteal 
mastoid abscess can only be surgical. The lateral surface of the mastoid 
process is exposed through the typical retro-auricular incision. In 
larger abscesses the greater portion of the contents may be evacuated 
with a trocar. If the outward perforation has already set in, the 
skin incision is made through the fistula, and the fistular wall is re- 
moved with the scissors. The abscess wall is cleansed with sharp spoons 
and sharp curettes, after which the mastoid process is opened in the 
typical manner. 

In acute middle-ear suppuration simple opening of the mastoid 
(mastoidotomy) will suffice, provided the bone in the direction toward 
the antrum is healthy. This holds especially good for all those cases 
where a suppurative middle-ear inflammation in the region of the tym- 
panic membrane has already run its course at the time of the operation 
(tympanic membrane closed, good hearing acuity) . Should there be still 
secretion from the external meatus, antrotomy is absolutely necessary. 
No cure may be expected from a mere puncture of the abscess or a 
simple incision. 

In infants antrotomy should be done in all acute cases. 

In chronic suppuration of the middle ear, radical operation has to 
be resorted to, as a matter of course. The extent of the same is to be 
adapted to the requirements of the middle-ear changes. s 

Prognosis. — The prognosis and the postoperative course depend 
upon the underlying affection. 

In large abscesses which have existed for a long time and led to 
extensive destruction of the periosteum, large, deep scars are to be 
expected. 

n. OSTEOPERIOSTITIS AND SUBPERIOSTEAL ABSCESSES OF THE TEMPORAL 
SQUAMA AND THE ZYGOMATIC PROCESS 

Subperiosteal abscesses in the region of the temporal squama 
and the zygomatic process are rather rare. They occur by outward 
perforation of the pus from the middle ear along the upper wall 
of the auditory canal and spreading of the pus to the squama and 
zygomatic process. 

Anatomy. — The affected bone exhibits all the signs of carious de- 
struction. The abscess walls are covered with granulations and the pus 



282 THE DISEASES OF CHILDREN 

is usually fetid. The bacterial examination reveals, in a large number 
of cases, bacteria of the coli group or of tuberculosis. The affection 
usually ends with complete destruction of the affected bone. 

Symptoms. — Abscesses in the region of the squama and zygomatic 
process of the temporal bone are mostly found in chronic tuberculous 
suppuration of the middle ear or in tuberculous syphilitics. Examina- 
tion of the ear usually reveals chronic, neglected suppuration of the mid- 
dle ear, abundant granulation, and secretion of fetid pus. The develop- 
ment of the condition is rather insidious, painless, and without any 
changes attributable to the middle-ear affection. The patient notices a 
gradual swelling of the affected region of the skull. There may be oedema 
of the lid and actual displacement of the bulbus upward and exophthal- 
mos in advanced cases. Spreading of the inflammation to the submaxil- 
lary articulation may cause transitory or permanent trismus, with a 
consequent difficulty in ingesting food. There are also lachrymation, 
conjunctivitis, and sometimes development of acute keratitis. Fever 
and central symptoms are usually absent, but there is diffuse headache. 

The diagnosis causes no difficulties to the experienced physician, 
but it requires a careful examination of the ear, since neither the patient 
nor his relatives usually have the slightest idea that the source of the 
affection lies in the middle ear. The descent of the upper wall of the 
auditory canal, occasional atresia of the external meatus, the presence 
of a fistula in the lateral attic wall, the destruction of the upper wall of 
the osseous auditory canal, the livid discoloration of the auditory canal, 
and the secretion of fetid pus through the external meatus, distinctly 
reveal the otogenic character of the affection. 

The differential diagnosis has principally to consider tuberculosis 
and syphilis of the cranial bones. Fracture of the skull, with regional 
subperiosteal hsematoma, may likewise present a similar picture. 

In multiple tuberculosis of the cranial bones other regions of the 
skull may likewise be tuberculous, such as the parietal bone, frontal 
bone, and orbital roof. Suppurative gummata in the region of the 
squama of the temporal bone or zygomatic process may sometimes sim- 
ulate an otogenic process. Precise establishment of the history, X-ray 
examination, and, if necessary, examination for complement deviation, 
will render the diagnosis possible. 

Atheromata are very rare in this region; nevertheless, an otitic 
abscess may exceptionally be simulated by a suppurative atheroma. The 
intact middle ear and the entirely unchanged auditory canal will lead 
to the correct diagnosis. 

Regional malignant tumors need not be considered for the purposes 
of differential diagnosis, except sarcoma. This may be either pure sar- 
coma or sarcomatous mixed growths of the parotid gland (which can be 



EXTRACRANIAL AFFECTIONS OF THE EAR 283 

easily recognized by their source) or medullary sarcoma of the dura. All 
these growths are perforated in all directions by the squama of the tem- 
poral bone and seem to have fluctuation. In the latter case there are 
always fetid suppuration of the middle ear and tormenting headache. 

Traumatic haematoma in the region of the squama of the temporal 
bone and zygomatic process after fractures occurs almost exclusively 
from direct trauma. Aside from the history, there are sufficient guiding 
points gained by an examination of the visible injuries of the neighbor- 
ing skin to assure the diagnosis. 

Treatment, Course, and Prognosis. — The treatment consists in the 
surgical exposure of the affected bone, but it should be remembered that 
operation in the region of the temporal squama or zygomatic process 
must always be preceded by antrotomy in middle-ear suppuration or by 
the radical operation in chronic cases. The skin incision should be made 
far enough forward to admit of reliable drainage of the abscess. In 
order to prevent disfiguring scars, the incision should always be made 
above the border of the hair if at all possible, and the zygomatic process 
be exposed by displacing the skin flaps. To expose the abscess itself 
great care is required. The soft layer is resected gradually and carefully, 
since a careless incision invites the danger of injuring the dura of the 
middle cranial fossa by perforating the temporal squama, which may 
already be impaired. 

The course generally is tedious, which is not surprising, as all these 
patients have been weakened from inadequate nutrition. Besides, there 
are very often accompanying tuberculosis and syphilis. 

The prognosis should, therefore, be very guarded. The course of 
the affection takes from two to four months; in tuberculous cases the 
possible subsequent development of tuberculous meningitis or cerebral 
tuberculosis should be taken into account. 

HI. FISTULA FORMATION IN THE OSSEOUS AUDITORY CANAL 

Fistula formation in the osseous auditory canal, as a sequel to middle- 
ear suppuration, occurs oftener in chronic than in acute cases. The fis- 
tula is generally situated in the lateral antrum wall. The destruction of 
the integument of the auditory canal, if it should take place, may not 
go beyond the locality of the fistula; sometimes, however, there occur 
extensive ulcerations of the integument of the auditory canal. The 
result will be the complete destruction of the membranous auditory 
canal and the formation of a circular ulcer. The fistula formation itself 
takes place in conjunction with the changes which lead to the expulsion 
of an antrum sequestrum or consequent upon acute ulcerative disinte- 
gration of a middle-ear cholesteatoma. The orifice of the fistula is 
sometimes more or less round in shape, sometimes in the shape of a fissure 





284 THE DISEASES OF CHILDREN 

running in the longitudinal direction of the auditory canal; in other 
cases, again, the latter shows cribriform perforation (Fig. 92). 

In chronic tuberculosis of the middle ear the integument of the 
auditory canal may happen to remain intact in spite of a fistula if the 
perforation makes only very slow headway (Fig. 97). As the ulceration 
advances, it causes the soft parts to be gradually detached from the bone 
of the external auditory meatus, with consequent prolapse of the wall of 
the canal (Fig. 97). The canal is flooded by pus on all sides, and the pus 
finally perforates at the transition from the osseous to the cartilaginous 
auditory canal, spreading forward to the submaxillary bone. In some 
cases there may be a descent of pus closely below the concha at the spot 

covered by the lobulus. In children the forward 

Fig 97 

perforation may occur through the ossification 
gap of the tympanic bone, leading to periartic- 
ular tuberculosis of the submaxillary articula- 
tion. This may finally cause perforation into 
the articulation itself. 

Symptoms. — Fistulae in the region of the 

otoscopic findings in fistula of osseous auditory canal may develop without 

i!"proi^psrof 0r the U posterior Ca waii hindrance. The permeability of the fistula is 

pis^s^oAroTt'elna. 6 indicated by considerably increased secretion 

of pus from the external meatus and is accom- 
panied by the destruction of the auditory canal. Small particles of bone 
or of the cholesteatoma are expelled along with the pus. Fistulae with a 
slow course of development may be completely occluded by polypi, and 
in these cases manifestations of pus retention will occur in spite of the 
presence of the fistula. They consist in slight but very fetid secretion, 
headache, greatly impaired hearing acuity, and a sensation of fulness and 
heaviness in the ear. Should, as it sometimes happens, the secretion be 
entirely arrested, there may be considerable elevation of temperature. 

Diagnosis. — A fistula of the auditory duct can usually be recognized 
in the otoscopic examination and demonstrated by the introduction of 
a bent button probe. Fistulae which are located near the border of the 
tympanic membrane may simulate perforation of the latter. Small 
fistulas which are located near the antrum wall may require careful 
examination for detection. The probe encounters rough bone. The 
manipulation of the probe requires great gentleness of action, owing to 
the danger of dislocating the auricular ossicles. Carelessness may also 
cause a paresis of the facial muscles, evidently by pressure on the ex- 
posed facial nerve. This, however, will only be transitory. 

Local anaesthesia should be induced in order to save patients any 
inconvenience during the local examination, but general anaesthesia is 
not required in any of the cases. 



EXTRACRANIAL AFFECTIONS OF THE EAR 285 

In the presence of intracranial or labyrinth symptoms (vertigo, 
vomiting, equilibrial disturbances), examinations with the probe and 
irrigations with the tympanic tube are, of course, to be avoided. With 
the integument of the auditory canal destroyed and in the presence of a 
large permeable fistula, the correct diagnosis can be made from the oto- 
scopic examination without resorting to instrumental examinations. 

The differential diagnosis will have to consider: Bone abrasions of 
the external auditory canal following circumscribed necrosis of the soft 
covers, particularly erosions of the external canal caused by acids, such 
as sulphuric or carbolic acid, fracture of the external canal. 

Course. — Left to itself, the fistular orifice will increase in size, the 
result being a complete destruction of the posterosuperior osseous wall 
of the canal. On examination we shall find the picture of the so-called 
"natural radical operation," with exposed attic and antrum. The suppu- 
ration of the middle ear, however, generally continues, and the number 
of cases in which the process can be arrested by conservative treatment 
is very restricted. 

In other cases there will be formation of osteophytes in the middle 
ear and external canal, organic stricture of the latter, circular ulceration 
of the integument, and atresia of the canal which may be permanent. 
Should, however, the perforation of the middle ear persist, and especially 
in the presence of a cholesteatoma, the atresia will again be broken down 
for the time being, or the occlusion may persist and the periodical per- 
foration will occur through fistula formation of the mastoid process. 

Treatment. — Spontaneous healing being a very rare occurrence, 
operation is the indicated treatment in every case of fistula of the audi- 
tory duct. This consists in the radical exposure of the middle-ear spaces, 
and is a very simple procedure, considering that the osseous wall has 
already been partially or completely destroyed. After the plastic opera- 
tion of the canal, the lividly discolored or ulcerated parts of the integu- 
ment of the canal must be resected. Should any pus descend toward 
the mastoid process or submaxillary articulation, it will be necessary 
to expose the abscess region in accordance with general surgical principles. 

The prognosis in non-tuberculous cases is thoroughly favorable, 
and identical with the prognosis of chronic middle-ear suppuration with- 
out fistula. Radiation by artificial light or sunlight often does excellent 
service in the traumatic treatment of tuberculous cases. As a matter of 
course, the physical condition of the patient should likewise be improved 
by adequate nutrition. 

Involvement of the submaxillary articulation and simultaneous 
presence of submaxillary ankylosis require two operations, as in most 
cases the ankylosis cannot be operated upon until the radical operation 
has taken place. 



286 THE DISEASES OF CHILDREN 

IV. OTOGENIC DESCENDING ABSCESSES OF THE SUBMAXILLARY REGION 
Pus descending toward the submaxillary articulation in the absence 
of a fistula of the auditory canal is exceedingly rare. It is observed in 
children in acute middle-ear suppuration following grave infectious 
diseases. In my own experience, the affected patients have not had 
medical attention in the acute stage, the middle-ear suppuration being 
left to take care of itself. 

The treatment should always set in simultaneously with the surgical 
treatment of the middle-ear suppuration. In fresh and all such cases 
in which the middle-ear suppuration has not existed for more than 
eighteen months, antrotomy will, as a rule, suffice. The submaxillary 
articulation may then be exposed and the ankylosis removed at the 
same time. Radical operation is unavoidable where the suppuration 
has existed for more than eighteen months. Operative interference with 
the submaxillary region is not indicated immediately following a radical 
operation, unless there is a florid suppuration or a descending abscess. 

V. DESCENDING ABSCESSES ALONG THE EUSTACHIAN TUBE 

Pus descending along the Eustachian tube is the only hyperacute 
affection among the extracranial otitic diseases. It is rare, and appears 
as a complication of grave acute or chronic suppuration of the middle 
ear, sometimes in the course of an ichorous bulbus thrombosis. There 
will be phlegmonous inflammation of the soft parts of the tube, with 
subsequent, rapidly advancing, degenerative suppuration. The latter 
continues partly in the form of submucous descending abscesses toward 
the pharynx; partly it causes acute, purulent pharyngitis, with suppura- 
tive laryngitis or laryngeal oedema due to destruction of superficial 
tissue; while in cases running a particularly rapid course there will be 
descent of pus toward the fundus of the buccal cavity, purulent peri- 
phlebitis, and venous thrombosis. 

The diagnosis of these cases is' not an easy one, the less so as patients 
often present themselves for examination when their condition is exceed- 
ingly complicated. 

The pharyngoscopic picture simulates a grave ulceration from a 
peritonsillar or retropharyngeal abscess, and the real cause of the trouble 
is only discovered by a careful examination of the auditory canal. 

The surgical treatment is often aggravated by the fact that it is 
difficult to open the descending abscesses sufficiently from the ear trauma 
(antrotomy or radical operation), and a reliable drainage by counter 
incisions at the neck or arch of the buccal cavity can not often be estab- 
lished. 

The prognosis is unfavorable in a large number of cases, the patient 
succumbing to the rapidly progressing purulent decomposition of the 



EXTRACRANIAL AFFECTIONS OF THE EAR 



287 



soft covers of the fauces and larynx, or a pyaemia may develop with all 
its sequelae. Nevertheless, there are also benign cases which recover as 
peritonsillar abscesses. 

The unfavorable prognosis is based in many cases upon the presence 
of infections caused by highly virulent pyogenic factors. 

VI. OTITIC DESCENDING ABSCESSES OF THE NECK AND SUBOCCIPITAL 
OTOGENIC SUPPURATION 

These affections are occasioned by downward perforation of a 
mastoid abscess. There is an anatomical predisposition in the fact that 
the cortical layer is very often thicker at the lateral surface of the mastoid 
process than at the apex or middle wall (Figs. 98, 98a, 99, 101). 

In the region of the mastoid cells especially, the cortical layer of the 
middle wall and apex are often found as thin as paper and transparent 



Fig. 9S. 



Fig. 98a. 




Normal mastoid process. The lateral wall of the 
corticalis (CI) is as thin as paper at the apex. 



Mastoid cells with diploic apex (A). The lateral 
cortex (CI) i? thick, the cortex of the apex (A) as 
well as the internal cortex (Cm) are thin. Ss, sul- 
cus sigmoideus. 



(Fig. 98), with the consequence that a gradually growing abscess, which 
reaches the cortical layer at about the same time, will perforate through 
the apex or middle wall (Figs. 99-101, 103) rather than through the cor- 
tical layer of the lateral wall. 

Up to the age of four years the mastoid process is but slightly de- 
veloped and the entire cortex is thin. In the neighborhood of the an- 
trum especially, the osseous wall of the mastoid is but slightly resistant, 
which accounts for the fact that in infancy perforations of the upper 
part of the mastoid with formation of subperiosteal abscesses occur 
oftener than descending abscesses of the neck or nape by perforation 
of the apex (Fig. 103). Otitic descending abscesses of the neck in infancy 
are caused by destruction either of the fundus of the tympanic cavity 
or of the inferior wall of the auditory duct or by the downward spreading 



288 



THE DISEASES OF CHILDREN 




of a subperiosteal abscess following a perforation of the periosteum out- 
side the perimysium of the sternocleidomastoid muscle (Fig. 102). 

Bezold was the first to study otitic descending abscesses both anatom- 
ically and clinically, and it is for this reason that mastoiditis which is 
accompanied by these manifestations is known as Bezold's (Fig. 99). 

According to the localization of the perforation, three kinds of 
descending abscesses can be distinguished (Fig. 101) : 

(1) Descending abscess within the sterno- 
cleidomastoid, the perforation occurring in the 
region of the insertion of that muscle (Fig. 100). 

(2) If perforation occurs through the inter- 
nal wall of the apex, the pus will appear in the 
spaces between the fascial layers of the neck and 
nape. 

(3) If the perforation occurs in the region 
of the insertion of the digastric muscle, the pus 
will invade that muscle. As the abscess grows, 
the digastricus will be flooded by pus, which 
finally descends in the direction of the tendon of 
that muscle, forward toward the pharynx and 
the arch of the buccal cavity. 

Course. — Superficial abscesses located in 
the sternocleidomastoid (Fig. 100) grow but 
slowly, the degree of growth depending upon 
purulent disintegration of the muscular tissue of the sternocleidomastoid. 
The abscess is always confined to the upper part of the muscle, and 
causes a flattened spherical swelling in the region of the sternocleido- 
mastoid which may be surrounded by extensive cedema (Fig. 100). 

After perforation into the facial fissures, large quantities of pus will 
rapidly descend. The advancing pus meets with but little resistance, and 
may within a few days reach the roof of the pleura and the clavicle in front 
and the scapula and cervical vertebral column behind. Besides, widely 
ramified abscesses will form between the superficial and deep muscles of 
the neck and nape (Fig. 103), and pus will descend toward the pharynx 
and sometimes perforate into the pharynx itself through its lateral wall. 
/ After perforation toward and into the digastric muscle the pus will 
descend toward the fundus of the buccal cavity, with phlegmonous 
inflammation of the vicinity. Here, again, a spontaneous perforation 
into the pharynx may sometimes occur. 

Symptoms. — There is always a suspicion of a descending abscess 
toward the neck where in the presence of mastoiditis the apex of the 
mastoid is not palpable (Fig. 100). Patients with short, thick necks 
are an exception, as in their case the apex may not be palpable although 
no inflammation whatever is present. 



Anatomy of Bezold's mastoi- 
ditis. A sequestrum is visible in 
the large fistular aperture (a) at 
the medial surface of the mastoid 
process. 



EXTRACRANIAL AFFECTIONS OF THE EAR 



289 



Fig. 100. 



There are all the manifestations of purulent mastoiditis. It is only 
in a relatively small number of cases that the inflammatory manifesta- 
tions of the mastoid recede after the occurrence of a downward perfora- 
tion. In rare cases the entire middle ear may completely recover, so 
that the mastoid, tympanic membrane, and hearing acuity are found 
normal. 

Superficial descending abscesses are accompanied by spontaneous 
and pressure pain in the region of the sternocleidomastoid. The motility 
of the head is impaired, the head being often held in oblique position, 
with inflection toward the af- 
fected and torsion toward the 
healthy side. After a descend- 
ing abscess has persisted for 
some time, the skin over it 
will be drawn tight and hy- 
persemic and there may also 
be fluctuation. In the early 
stage fluctuation may be en- 
tirely absent if there are con- 
siderable swelling and inflam- 
matory infiltration of the 
muscle. 

Pus descending along the 
facial fissures usually causes 
pain in the shoulder axillary 
region. This may be mis- 
taken for muscular rheuma- 
tism if the middle-ear inflam- 
mation itself has already 
healed by that time. If the 
abscess extends anteriorly to 
the pharynx, it can be felt in the shape of a resistant protrusion of the 
lateral pharyngeal wall by digital examination from the pharynx. After 
perforation into the pharynx the patient feels a sweetish pus taste in the 
mouth and complains of anorexia. In some cases pus is expectorated or 
vomited. In deep perforation there is violent headache, with difficult 
deglutition and mastication. In the acute stage there is usually contin- 
uous fever; in later stages the temperature may be normal. 

Diagnosis. — The diagnosis of superficial descending abscesses of 
the neck is exceedingly simple. Any previous or still existing mastoi- 
ditis, together with the fact that the pain in the mastoid was less or 
arrested after the growth at the neck occurred, will at once suggest an 
otitic descending abscess. 

VI— 19 




Left otitic descending abscess. The flattened spherical 
swelling of the submastoid region of -the neck (a) is distinctly 
visible in the posterior aspect. 



290 



THE DISEASES OF CHILDREN 



Fig. 101. 



Where, however, perforation into the deeper layers of the neck has 
persisted for some time, the diagnosis may cause difficulties. Such is 
particularly the case if at that time the middle-ear inflammation has 
already abated and no abscess symptoms are demonstrable at the mas- 
toid process. It is by no means a rare occurrence for patients to 

come to the ear specialist after a 
number of other examinations have 
been fruitless; patients may have 
been locally treated for weeks under 
the diagnosis of acute rheumatism 
or acute swelling of the lymph- 
glands, without as much as a 
thought having been given to the 
etiological importance of middle- 
ear inflammation. 

For purposes of differential 
diagnosis the following affections 
have to be considered: 

(1) Acute muscular rheumatism. 

(2) Acute inflammation of the 
deep lymph-glands of the neck 
and nape. 

(3) Tuberculosis of the cervical 
vertebral column. 

(4) Osteomyelitis of the cervi- 
cal vertebrae. 

(5) Tumors of the cervical ver- 
tebral column. 

In most cases there is no diffi- 
culty. The history and examina- 
tion of the neck (inspection and 
palpation from behind, Fig. 101) 
will positively reveal the otogenic 
character of the affection. 
The condition of the cervical vertebral column is found by X-ray ex- 
amination. In muscular rheumatism good motility of the head and neck 
for at least several hours, or possibly complete disappearance of the com- 
plaint, will be attained by hot-air treatment, while the same treatment 
can, of course, have no favorable effect upon descending abscesses. 

The difficulties are greater in many cases of deep abscesses of the 
lymph-glands, especially -since otitic descending abscesses may in every 
case cause swelling or suppurative inflammation of glands and forma- 
tion of actual glandular abscesses of the neck. If the history fails to 
establish any affection of the ear, if tympanic membrane and mastoid 




Schematic frontal section through the right mastoid 
process, illustrating the topographico-anatomical con- 
dition in otitic descending abscesses. Natural size. 
pm, mastoid process; Ic, lateral (thick) corticalis of 
the mastoid process; p, periosteum; ap, apex of the 
mastoid, in this case enclosed by a thin cortex; 
msc, sternocleidomastoid muscle; F, fascial spaces; 
me, medial corticalis of the mastoid (in this case thin) ; 
md, museulus digastricus; sm, sulcus mastoideus; 
pe, petrous bone. 

The mastoid abscess (A) is prevented from per- 
forating outward by the thick lateral corticalis; it 
therefore perforates downward either into the sterno- 
cleidomastoid (type 1), into the fascial spaces (type2) 
or into the museulus digastricus (type 3), forming a 
descending abscess (see p. 288). 



EXTRACRANIAL AFFECTIONS OF THE EAR 



291 



process are intact, and the hearing acuity is normal, the otitic char- 
acter of the affection may be excluded, as a rule. In doubtful cases, 
however, the differentiation can only be made on the operative findings. 

An otitic descending abscess of the neck extends from some circum- 
scribed place to the exposed bone or upwards to a mastoid fistula, while 
a glandular abscess is surrounded on all sides by soft parts. 

Treatment. — The treatment of otogenic descending abscesses of the 
neck consists in incision and evacuation. The first step of the opera- 



Fig. 102. 




Otitic descending abscess, the pus descending toward the nape. Four-year-old girl. 



tion is always opening of the mastoid, including cases in which clinically 
no more mastoid manifestations can be detected. If at the time of opera- 
tion the tympanic membrane is closed and there is good hearing acuity, 
mastoidotomy will suffice. The apex of the mastoid is then exposed, 
its lateral wall and base are incised, and the fistula should be demon- 
strated, if possible. 

If the fistula is located at the apex, it can be completely removed; 
where it is located at the middle surface of the apex, it should be simply 
transformed into an open groove by removing the lateral wall, as more 
extensive resection of the bone invites the danger of exposing or injuring 
the facial nerve. 

Should pus exude from the external auditory meatus at the time of 
operation, or the acuity be considerably reduced in spite of a closed 



292 



THE DISEASES OF CHILDREN 



Fig. 103. 



tympanic membrane i^Yr-^Vi feet C), the preliminary act of the abscess 
operation should consist in antrotomy, or in chronic cases, of course, in 
the radical operation. 

In abscesses extending between the fascial lamina?, the skin incision 
is made very deep in order to reach the deepest point of the abscess, thus 
making sure that the entire abscess will be drained and further descend- 
ing of pus need not be feared 
(Fig. 103). The descending ab- 
scess is opened by enlarging the 
retro-auricular skin incision. 

In abscesses within the per- 
imysium of the sternocleidomas- 
toid, it will be sufficient to elon- 
gate slightly the skin incision 
beyond the apex of the mastoid, 
because after evacuation of the 
abscess any extensive descend- 
ing of pus will no longer occur, 
owing to the resistance of the 
muscular tissue. If necessary, 
counter-drainage may be pro- 
vided at the lower end of the 
abscess. 

If at all possible, the skin 
incision should be made along 
the anterior border of the ster- 
nocleidomastoid. Any pressure 
tending to expel the contents of 
the abscess should be avoided, 
all that is necessary being to provide a suitable aperture through which 
the pus may spontaneously flow off. The healing process will then usually 
run a smooth course. Should the opening be insufficient, voluminous secre- 
tions of pus will continue for days or weeks, until sudden pain and fever 
indicate new progress of pus descending or the formation of a new abscess. 
Intramuscular abscesses, even large ones, will heal without causing 
motor disturbance of the head or vertebral column, except in cases where 
the healing process is slow and children have to wear a head and neck 
support. This may cause oblique position of the head, which, however, 
will spontaneously remedy itself or completely disappear under hot-air 
treatment. Massage should not be instituted for a long time afterward. 
If there was perforation toward the pharynx, drainage strips should 
be inserted up to the aperture of the perforation. The pharyngeal 
fistula will heal spontaneously and completely without any local treat- 
ment in 1-4 weeks after the descending abscess has been opened. 




Bezold's mastoiditis. Scars after healing of multiple, widely 
ramified, descending abscesses of the neck. 



XIII. ENDOCRANIAL OTOGENIC AFFECTIONS 

The most important endocranial otogenic affections in infancy and 
early childhood are pachymeningitis externa, extradural abscesses, and 
serous, suppurative, and tuberculous meningitis. Otitic thrombophle- 
bitis is less frequently observed in infants and children under four years 
of age. It appears that they acquire suppurative meningitis much more 
readily under the same circumstances which cause serous phlebitis in 
older children and adults. This may be attributable to the fact that the 
cranial surfaces of the temporal bone in infants and young children are 
much more intimately connected with the external surface of the dura 
than is the case in older children or adults. 

The cases of cranial abscess observed in children during the first 
years of life are almost without exception suppurative cerebral tubercles 
of the third ventricle or cerebellum. 

I. PACHYMENINGITIS EXTERNA AND EXTRADURAL ABSCESSES 

Occurrence. — Extradural abscesses spreading between the bone and 
the dura always occur in conjunction with inflammation of the external 
surface of the dura (pachymeningitis externa); occasionally they even 
represent the end result, pachymeningitis externa. The cases in which 
pachymeningitis or extradural abscesses develop in the course of acute 
middle-ear suppuration are to be clinically strictly separated from those 
occurring in the course of chronic middle-ear suppuration. According 
to the length of time the dural changes have persisted, we distinguish 
between the acute and chronic extradural abscess. According to local- 
ization, we distinguish extradural abscesses of the middle cranial fossa 
and those of the posterior cranial fossa. The extradural abscesses 
situated between the surface of the petrous bone and the dura may be 
designated as paralabyrinthine ; those in the area of the venous sinuses, 
especially the sinus sigmoideus, the middle wall of which is formed by 
the dura and the sinus, are called perisinous (wrongly perisinuous) 
abscesses. 

In many cases pachymeningitis and extradural abscesses are part 
manifestations, the beginning or termination of some other endocranial 
otitic affection (sinus thrombosis, meningitis, cerebral abscess), or of a 
suppuration of the labyrinth. It may happen in very rare cases that a 
suboccipital otitic descending abscess, which has originated at the base 
of the brain, penetrates up to the dura through the osseous base of the 
skull, involving the external surface of the dura or leading to extradural 
abscess. 

293 



294 THE DISEASES OF CHILDREN 

Anatomy. — Pachymeningitis externa and extradural abscesses, like 
other intracranial affections, may occur by direct spreading to the dura 
and the extradural spaces of a pus focus that may be present in the tem- 
poral bone, or by way of metastasis. In the former case the temporal 
bone is usually softened up to the dura, and there is already a more or 
less extensive osseous fistula which is permeable up to the dura. 

If the changes are of metastatic origin, the temporal bone in the 
region of the abscess or of the extradural affection may appear macro- 
scopically intact, in which case the lateral wall of the abscess is formed 
by the normal cortical layer of the cerebral or cerebellar surface of the 
temporal bone. 

Pachymeningitis externa sets in with the secretion of a fibrinous exu- 
date between dura and osseous surface, the first effect of which is the sepa- 
ration of the dura from the bone. This means that the intimate union 
between dura and bone which prevails in young children must be sev- 
ered by the exudate. It does not require a long time for fibrinous layers 
to appear on the external surface of the dura. They are grayish white or 
yellowish white, completely cover the bluish-white color of the dura, and 
are coarse to the touch. The periphery of these pachymeningitis plaques 
is sharply demarcated and encircled by perfectly normal dura. Pus will 
now form with the aid of micro-organisms, accumulating between dura 
and bone. This accumulation, so far as its surface extension is concerned, 
may be restricted to the area of the original changes. In many cases, 
however, especially in those where the pus is under considerable pressure, 
the dura will be lifted up from the bone for an extensive area, and there 
will be extensive superficial abscesses. 

In abscesses which have been caused by direct extension of suppura- 
tion of the ear there is usually from the first a communication between 
the extradural abscesses and the hollow spaces of the temporal bone. As 
in these cases the pressure in the extradural abscess is not particularly 
high, extensive extradural abscesses which have spread in continuity of 
process are very rare. On the other hand, abscesses which were caused 
by metastasis and are closed in from all sides may assume very large 
proportions, and in rare cases lead to suppuration of a large part of the 
dura of the posterior or middle cranial fossa on the affected side, and to 
secondary perforation outward. 

Abscesses of the posterior cranial fossa are bounded in most cases 
at the level of the sinus transversus and the superior edge of the petrous 
bone. Exceptions, however, are by no means rare, so that a perisinous 
abscess of the posterior cranial fossa may spread from the knee of the 
sinus upward to the middle cranial fossa; or a paralabyrinthine abscess 
or an extradural abscess of the middle cranial fossa, situated above the 



ENDOCRANIAL OTOGENIC AFFECTIONS 295 

antrum, may spread beyond the upper edge of the petrous bone to the 
posterior cranial fossa. 

The depth of extradural abscesses varies. As a rule, they do not ex- 
ceed a few millimetres. On the other hand, some acute extradural 
abscesses of the posterior cranial fossa which descend toward the occiput 
may give rise to considerable accumulation of the pus at the base of the 
occiput. Deep extradural abscesses of the middle cranial fossa, accom- 
panied by compression of tho cerebrum (temporal and parietal lobes of 
the affected side), are very seldom observed. In this region there are 
only chronic extradural abscesses with acute exacerbation. The latter 
may be caused by trauma (fall, sabre cut, horse kick, etc.) or by reinfec- 
tion in the course of chronic middle-ear suppuration. 

If pachymeningitis externa or an extradural abscess has existed for 
a long time, granulations will form at the walls of the abscess. Should 
there be an osseous fistula, this will be first attacked by granulations, 
next the external surface of the dura, and finally the surface of the bone 
facing the dura. 

Anatomical Course and Termination. — Pachymeningitis externa 
and extradural abscesses may heal spontaneously in the early stage of 
the affection. The contents of the abscess are partly resorbed and partly 
undergo connective-tissue organization. The granulations are gradually 
replaced by connective tissue. The rest of the changes consist in thick- 
ened layers of connective tissue, in deposits on the dura mater, and in a 
particularly intimate connection of the dura with the bone. 

In the absence of resorption and spontaneous healing the extradural 
abscess will finally perforate in. the neighborhood. Perforation outward 
will be favored by the presence of an osseous fistula which precedes 
abscess formation in cases where the abscess is the result of a continuous 
process. In cases of metastatic extradural abscesses the fistula may be 
formed at a later period. 

According to locality there are to be distinguished: (1) fistula of 
the mastoid, (2) of the antrum, (3) of the tegmen, (4) of the labyrinth. 

The mastoid fistula is located in the posterior cranial fossa at the 
medial surface of the mastoid, and is most frequently observed in extra- 
dural abscesses and usually causes a broad communication between the 
extradural and the mastoid abscess. 

An extradural abscess may be evacuated into the antrum or tym- 
panic cavity through a fistula of the antrum or tegmen. 

Should an extradural abscess lead to the formation of a labyrinth 
fistula, it is usually one of the upper semicircular canal, and it invari- 
ably attacks a canal which is provided with a thin bony layer of slight 
resistance. The consequence is suppuration of the labyrinth, followed 
possibly by sequestration of the labyrinth. 



296 THE DISEASES OF CHILDREN 

The contents of an extradural abscess first reach the hollow spaces 
of the temporal bone through the fistulse. Here the pus may either be 
arrested, leading to abscess formation in the labyrinth or middle-ear 
spaces, or it may finally perforate outward through the lateral surface 
of the mastoid, forming a subperiosteal mastoid abscess. 

As a rule, otitic extradural abscesses which have originated in the 
ear perforate outward into the region of the temporal bone. Exceptions 
are rare. I observed a case where an otitic extradural abscess of the 
middle' cranial fossa perforated through the sphenoid bone, the pus 
spreading along the inner surface of the temporal muscle and in the 
muscle itself. In two cases of extradural abscess of the posterior cranial 
fossa, perforation with formation of a suboccipital descending abscess 
occurred through the basal part of the occipital bone, which was very 
thin. In one case perforation occurred through the parietal bone. 

An extradural inflammation is spread to the endocranium by fistula 
formation in the dura, either by continuity without a fistula or by way of 
metastasis. The affection terminates by infection of the venous sinuses 
with purulent thrombophlebitis and pyaemia, sometimes by a sinus fistula, 
by pachymeningitis interna, pachyleptomeningitis, encephalitis, or cere- 
bral abscess. 

Symptoms. Clinical Course. — Pachymeningitis externa and extra- 
dural abscesses of the middle cranial fossa are in most cases associated 
with localized headache. The pain is of a stinging nature and restricted 
to certain regions of the head, which, however, do not coincide with 
the anatomical seat of the lesion. The pain may even be referred to 
the opposite side of the skull. 

Affections of the external surface of the dura mater of the posterior 
cranial fossa are likewise accompanied by pain. This is usually referred 
to the mastoid region and is then a part manifestation of the other 
mastoid symptoms. There is also pressure pain immediately behind the 
mastoid, which is an exceedingly characteristic sign for pachymeningitis 
externa and extradural abscesses of the posterior cranial fossa. Sometimes 
there is also oedema in the same region or pain in the nape of the neck. 

There is moderate fever in acute abscesses, while in older and exten-^ 
sive abscesses or in extradural abscesses which have perforated outward 
the temperature may be perfectly normal. 

Extradural abscesses which are accompanied by considerable com- 
pression of the brain may lead to manifestations of cerebral pressure and 
infected foci, in exceptional cases even to all the symptoms of a suppura- 
tive pachyleptomeningitis and cerebral abscess. In otitic extradural 
abscess of the middle cranial fossa, for instance, spasms of the facial 
muscles and extremities are not infrequently observed. Large extradural 
abscesses on the left side may cause temporary disturbances of speech 



ENDOCRANIAL OTOGENIC AFFECTIONS 297 

in right-handed people (amnestic aphasia). Large acute extradural 
abscesses of the middle cranial fossa, which have grown rapidly, may 
cause unconsciousness and delirium; large extradural abscesses of the 
posterior cranial fossa may cause disturbance of coordination or abdu- 
cent paralysis on the affected side. The fundus of the eye is normal in 
pachymeningitis externa, small abscesses, and where an extradural abscess 
communicates with the middle-ear spaces. Closed extensive extradural 
abscesses, however, may lead to bilateral venous stasis of the fundus, 
and examination will show pathological repletion of the veins. Pro- 
nounced choked disk, however, is not of frequent occurrence. The fluid 
obtained by lumbar puncture is normal in many cases, but in extensive 
subacute or chronic extradural abscesses it is sometimes turbid. It will 
show very minute fibrin coagulation in from six to twenty-four hours, and 
the microscope reveals varying quantities of mononuclear and polynuclear 
leucocytes, but is sterile both under the microscope and in culture. 

In extensive abscesses of the posterior cranial fossa which extend 
to the neighborhood of the foramen magnum or have perforated outward 
extracranially there will be oblique position of the head toward the 
healthy side, impairment of active and passive motility of the head and 
cervical vertebral column, and sometimes stiffness of the neck. 

Diagnosis. — The pathological manifestations of extradural abscesses 
are divided into three stages, — (1) the initial, (2) the latent, (3) the 
manifest stage. 

The first stage is characterized by headache, which in abscess of 
the posterior cranial fossa is experienced as pressure pain immediately 
behind the mastoid. The cerebral symptoms above referred to occur 
in large extradural abscesses. In many cases there is moderate elevation 
of temperature. 

After two or three weeks the latent stage sets in. The temperature 
has usually returned to normal, and, unless there is considerable pressure 
in the abscess, subjective complaints may be entirely absent. Extra- 
dural abscesses at this stage are usually discovered accidentally on the 
occasion of some other ear operation. 

The acute stage occurs quite suddenly, the manifestations setting 
in without warning and causing acute reinfection of a chronic middle-ear 
suppuration. Any kind of trauma may be the means of changing the 
latent stage into the acute under grave symptoms. 

The experienced physician will have no difficulty in diagnosing the 
acute stage, as there are characteristic signs revealing an affection of the 
external surface of the meninges, — above all, localized headache, pres- 
sure pain immediately behind the mastoid, and perhaps oedema. Exami- 
nation of the auditory canal will likewise furnish important guides, as 
nearly all extradural suppurative inflammations in the region of the 



298 THE DISEASES OF CHILDREN 

middle cranial fossa are associated with suppuration of the antrum and 
attic. On the other hand, acute extradural abscesses and pachymenin- 
gitis of the posterior fossa are nearly always accompanied by inflammatory 
changes of the mastoid, although there need not be pronounced mastoid- 
itis, nor even an abscess. 

In other cases the very absence of certain symptoms will suggest 
the correct diagnosis. Thus, symptoms with cerebral foci, which are 
not accompanied by any great elevation of temperature or delirium, 
will suggest extradural abscess; the same holds good for isolated abdu- 
cent paralysis or other manifestations of a cerebellar abscess without 
any symptoms of acute suppuration of the labyrinth. 

An exceedingly valuable diagnostic symptom of extradural abscess 
and pachymeningitis is furnished by the operation, provided the bone 
at the dura is softened or fistulous. Having opened the mastoid, or the 
antrum in abscesses of the middle cranial fossa, pulsating pus will be 
found. This is the cerebral pulsation which has. been communicated 
to the pus by the exposed dura. In the presence of this symptom, it is 
always necessary to remove the softened bones and freely to expose 
the affected dura. 

As to the differential diagnosis of pachymeningitis externa and extra- 
dural abscess, all other intracranial otitic affections have to be considered. 

The differential diagnosis between extradural abscess and thrombo- 
phlebitis of the sigmoid sinus presents no difficulties in most cases. If 
no chills have preceded and there is no intermittent fever, the clinical 
symptoms which point to an otitic involvement of the posterior cranial 
fossa may with certainty be referred to extradural abscess, to the exclu- 
sion of a sinus involvement. 

On the other hand, it is impossible to differentiate between an extra- 
dural abscess at the level of the dura and one at the level of the venous 
sinus, because a perisinous abscess does not differ in treatment or prog- 
nosis from other extradural abscesses. The inflammatory changes of 
the externaL surface of the venous sinus are never accompanied by pysemic 
manifestations. An extradural abscess may represent the termination of 
an.inflaniniatory sinus thrombosis, provided the thrombotic contents of the 
sinus are suppurative and the endosinus abscess has perforated outward 
between dura and bone. There will be no difficulty if a precise history 
is available from the beginning of the affection. Should, however, these 
data be insufficient or entirely wanting, no other diagnosis can be made 
but that of extradural abscess, while the underlying cause, the question of 
any preceding thrombophlebitis and the presence of an endosinous abscess 
which has perforated outward, can only be established at the operation. 

It is possible for cerebellar symptoms to occur in the course of 
large extradural abscesses, but, from the fact that the former are nearly 



ENDOCRANIAL OTOGENIC AFFECTIONS 299 

always accompanied by suppuration of the labyrinth, the absence of 
such suppuration will point the way to the diagnosis of extradural 
abscess. 

Pachyleptomeningitis can be differentiated by the temperature. 
Moderately elevated or normal temperature points to extradural abscess, 
high fever to pachyleptomeningitis. Furthermore, the exudate obtained 
in lumbar puncture in suppurative pachyleptomeningitis contains micro- 
organisms ; that in extradural abscess may be clear or turbid, but is always 
sterile. 

The differential diagnosis between extradural abscess of the middle 
cranial fossa and abscess of the temporal lobe may give rise to difficulties, 
as many advanced cases of cerebral abscess are complicated by involve- 
ment of the external surface of the dura and actual extradural abscesses. 
Long persistence of the symptoms (for weeks or months) points to extra- 
dural against cerebral abscess. In the latent stage of a temporal abscess 
an exact differentiation can only be made at the operation. In abscess 
of the temporal lobe there will be circumscribed, more or less grave 
disturbance of the circulation (stasis, thrombosis), while in extradural 
abscess the blood-vessels of the dura are unchanged. 

The clinical differentiation between extradural abscess and tumor 
of the dura is easy in the absence of any suppurative involvement of 
the middle ear, so that there is no cause for an abscess to form. In these 
cases the first thought should be of a tumor. Sometimes, however, an 
extradural tumor develops on the soil of an old middle-ear suppuration, 
and in these cases which involve sarcoma of the dura a clinical differen- 
tiation before operation is practically impossible. The time of operation 
is certainly early enough to make a diagnosis of tumor, as the temporal 
bone is not found to be softened from suppuration. 

It is only in very rare cases that symptoms of extradural abscess 
can be caused by cholesteatoma of the dura. The clinical observations 
of such a case were recently reported by Frey. 

It is important to bear in mind that the value of the clinical differ- 
ential diagnosis should not be overestimated. As in all other diseases, 
it is not so much a question in otitic intracranial affections to diagnos- 
ticate their anatomical character and depth toward the brain, but to 
recognize the affection before operation. It is a perfectly satisfactory 
achievement to make a diagnosis in doubtful cases of a pathological 
involvement in the region of the middle or posterior cranial fossa. This 
diagnosis is a sufficient indication for immediate operation, because an irri- 
perfect clinical diagnosis may be supplemented by the operative findings. 

Treatment. — The fact of a middle-ear suppuration having led to a 
pathological involvement of the external surface of the dura or to an 
extradural abscess is a sufficient indication for immediate operative 



300 THE DISEASES OF CHILDREN 

interference. Spontaneous healing of extradural abscesses and pachy- 
meningitis is too rare an occurrence to be therapeutically foreseen with 
the slightest justification. Conservative treatment and a waiting atti- 
tude are still less justifiable. 

Operation. — Surgical exposure of the affected dura is done through 
the ear. The mastoid is opened, and, if the underlying middle-ear sup- 
puration is acute, antrotomy will be sufficient. In chronic suppuration 
of the middle ear, however, resection of the dura must be preceded by 
the radical operation. Operations in the region of the dura can only be 
done after the ear operation has been completed. In extradural abscesses 
caused by suppuration of the labyrinth, the affected dura must be ex- 
posed by resection of the affected part of the petrous bone. In opera- 
tions on the dura itself as well as on the venous sinus, care should be 
taken that the bone is removed, flat before the actual exposure of the 
dura or sinus is undertaken. The reason is this : After the dura has been 
opened with the chisel at a circumscribed place, the further exposure 
can be accomplished with the bone-forceps from the aperture made or 
through an existing fistula, so that the dura will become visible, if pos- 
sible, on the level of the entire surface of the bone and not through a 
deep, funnel-shaped opening made with the chisel (Fig. 111). The 
direction of the chisel should be as near a tangent to the dura as possible. 

If the bone is removed with the bone-forceps, it is necessary first to 
remove carefully all adhesions between the bone and the dura by an 
elevator or a button probe, in order to prevent an accidental injury to the 
dura with the chisel or the bone-forceps. The exposure of the dura, if 
necessary beyond the region of the temporal bone, should be continued 
far enough to render the entire affected region of the dura freely visible 
in such a manner that it is surrounded by at least 5 mm. of normal dura. 
It is only by observing this rule that an incomplete exposure or evacua- 
tion can be prevented. It will also guard against the danger of the 
abscess spreading, in spite of the operation, along the surface or even 
penetrating intracranially. 

By correctly planning the operation the surgeon is to a certain 
extent independent from the clinical diagnosis. It has already been 
mentioned that, aside from the extradural abscess, there may be another 
endocranial affection which is clinically covered by the symptoms of an 
extradural abscess and may therefore escape attention. This applies 
especially to an extradural abscess which occurs in the course of a chronic 
middle-ear suppuration. Such a complication, however, is sure to be 
discovered by a systematic arrangement of the operation, and in this 
way I have repeatedly been in a position to demonstrate at the operation 
the clinically diagnosticated extradural abscess and incidentally dis- 
cover an intrameningeal or cerebral abscess. If the abscess extends over 



ENDOCRANIAL OTOGENIC AFFECTIONS 301 

a large area, the surgeon should not hesitate to carry out an extensive 
removal of the bone, — to the parietal bone, the temporal squama, the 
occipital bone, and, in rare cases, to the large sphenoid wing. 

The cavity is drained with iodoform wicks, but the principal wound 
is left open. If the healing process takes a favorable course without 
temperature, the first change of bandage is made on the sixth day 
after operation, the wicks being simultaneously shortened. This is 
repeated with each change of bandage, so that the drains introduced 
at the operation will be completely removed at the third or fourth 
change of bandage. The first change is made with the patient in the 
recumbent position, the operating room being most suitable for the 
purpose. The retro-auricular skin incision may be closed on the tenth 
day by sutures, with the exception of the middle third. 

Should pain, fever, or chills occur after the operation, the bandage 
should be immediately changed. 

The prognosis of pachymeningitis and extradural abscess is quite 
favorable, provided the operation has been done in time and correctly. 
Healing occurs by connective-tissue scars. The bone defect caused by 
the operation remains unchanged for the time being. In young and 
otherwise perfectfy healthy individuals there will in course of time be 
new-formation of bone from the external cortical layer of the mastoid, 
which will partly fill up the gap. There will be but slight new-formation 
of bone of the internal cortical layer of the temporal bone. 

After the healing process has taken its course, the periosteal scar 
will be sufficiently firm and resistant to render the use of prostheses or 
pelotes superfluous. 

II. OTITIC THROMBOPHLEBITIS, OTOGENIC PYEMIA, BACTEREMIA, AND 
TOXEMIA (SEPTICEMIA) 

(Synonyms: Otitic sinus phlebitis and sinus thrombosis.) 

Otitic thrombophlebitis is clinically a very important affection 
among the intracranial diseases occurring in the course of suppuration 
of the ear. It occurs much more frequently in acute than in chronic 
middle-ear suppuration. 

Etiology. — Thrombophlebitis is caused either by the suppurative 
middle-ear inflammation spreading to the venous sinuses or by way of 
metastasis; in the former case the anatomical signs of purulent inflam- 
mation can be demonstrated by continuity of process. 

It is a questionable point whether toxins secreted by the inflamed 
region into the neighborhood can lead to suppurative inflammation of 
the cerebral sinuses. 

Introductory Anatomical Remarks. — The venous sinuses are con- 
tained in the dura mater and form a network which separates the ear 



302 THE DISEASES OF CHILDREN 

from the cerebral cavity. This net is composed of the centrally situ- 
ated sinus cavernosus; the sinus sigmoideus and sinus transversus, which 
fuse with the periphery; the sinus petrosus inferior, sinus petrosus super- 
ior, and the sinus petrosquamosus (present in children, but usually absent 
in adults), which run over the petrous bone. 

The part where the sinus sigmoideus fuses with the vena jugularis 
likewise shows close topical relations to the ear. The bulbus venae 
jugularis, which is accommodated in the fossa jugularis, lies under the 
fundus of the tympanic cavity. The venae condyloidese inosculate into 
the bulbus direct. Immediately below the bulbus medium-sized veins 
empty into the vena jugularis and form a direct communication between 
the veins of the vertebral canal and the jugularis interna. Neither the 
cerebral sinuses nor the vena jugularis interna possess any valves. 

The vena facialis communis is the only one of those inosculating 
somewhat more centrally into the vena jugularis interna which is of 
any interest for our purposes. It communicates with the jugularis at 
the transition between the middle and upper third of the neck, but 
there are considerable deviations in altitude as to the place where this 
communication takes place. 

The vena jugularis itself crosses in its course the sternocleidomas- 
toid ; in the middle third of the neck it lies immediately behind the an- 
terior border of the muscle, in the lower third near the posterior border 
of the muscle, and in the upper third in front of the sternocleidomastoid 
muscle. Interposition of glands and fascia, together with the nervus 
accessorius, effect a separation at the latter place, which consequently 
lies in the deep layer of the soft parts of the neck. The vena jugularis 
is more superficially situated in the middle third and is separated there 
from the medial surface of the muscle merely by the fascia of the vasculo- 
nervous tuft. In the latter will be found the vena jugularis and the 
carotid at about equal depth, the pneumogastric nerve slightly deeper, 
and the sympathicus considerably deeper. A cross section of this bundle 
shows that the jugularis is completely isolated in it by a thick vascular 
sheath from the carotid and the two nerves, so that the vein can be 
completely brought to view without exposing the two nerves and the 
carotid. 

Introductory Physiological Remarks. — The blood-pressure in the 
vena jugularis and the regional cerebral venous sinuses is not great 
under normal conditions. It is even negative when the head is held erect 
and a position of deep inspiration assumed. It is higher and positive in 
the recumbent position and drooping head. The blood stream in the 
cerebral venous sinuses is directed toward the foramen jugulare under 
normal conditions, so that for instance the sinus blood of the right side 
of the head escapes through the right bulbus and the right jugularis 



ENDOCRANIAL OTOGENIC AFFECTIONS 



303 



interna. The current is stronger in the axis of the vessel than in the 
periphery; in the immediate proximity of the sinus wall the blood has 
but little motion, although the possibility of currents at the knee of the 
sinus sigmoideus and the head of the bulbus jugularis is admitted. The 
vena jugularis collapses more or less completely under negative pressure, 
but the venous sinuses and bulbus remain permeable through normal 
fixation of their lateral wall. An empty venous sinus always indicates a 
peripheral occlusion preventing the supply of blood. The sinuses can 
only collapse under negative pressure or after evacuation of the blood 



Fig. 104. 




Cross-section through the sinus sigmoideus in infectious thrombophlebitis, a, considerable callous thickening 

of the sinus wall; b, remnant of lumen. 

they contain, if the lateral sinus wall has been detached from the bone 
and becomes movable through pathological processes (pachymeningitis, 
extradural abscess). 

Pathological Anatomy. — The following inflammatory changes have 
to be distinguished: (a) the sinus wall, (b) the sinus contents, (c) the 
immediate surroundings of the sinuses. 

(a) The changes of the sinus wall correspond to the various stages 
of the phlebitis. As soon as the inflammation has spread by way of 
continuity from the region of the ear to the sinus, they set in with in- 
flammatory infiltration and suppuration of the external connective- 
tissue layers (suppurative periphlebitis). In some cases a perisinous 
(extradural) abscess develops between the lateral sinus wall and the 
bone. Periphlebitis leads to inflammation of the venous wall itself and 
finally to destruction of the endothelium (Fig. 104). The destruction 
of the endothelium is followed by partial (parietal) or complete (obturat- 



304 



THE DISEASES OF CHILDREN 



ing) thrombosis of the sinus contents. The inflammation may also 
spread to the medial sinus wall and to the medial surface of the regional 
dura mater (pachymeningitis interna). Should the thrombotic con- 
tents be suppurative, they will perforate outward and cause a fistula to 
form at the lateral wall. A rare contingency consists in fistula formation 
at the medial surface of the sinus, causing either an intrameningeal 
abscess or diffuse suppurative meningitis. 

(b) The changes of the sinus contents are characterized by the 
inflammatory thrombosis, which is caused in the first place by the de- 
struction of the endothelium at the inflamed place of the sinus wall. 



Fig. 105. 




Obturating, infectious, fusiform 
thrombus with pointed ends. Nat- 
ural size. Removed by operation 
from the sinus sigmoideus. Oto- 
genic pyaemia with infectious 
thrombosis of the jugularis (see 
Fig. 110) in the course of a middle- 
ear suppuration complicated by 
ichorization of a cholesteatoma. 
Recovery. 



Fig. 106. 




Infectious thrombus, natu- 
ral size, removed by operation 
from the sinus sigmoideus of 
a nine-year-old boy. Oto- 
genic streptococcus pyaemia 
with pachymeningitis in the 
course of acute scarlatinous 
otitis. Recovery. 



Fig. 107. 




Thrombus, natural 
size, removed by opera- 
tion from the sinu_ sig- 
moideus, sinus trans- 
versus, and the bulbus 
jugularis. Pyaemia in 
the course of a sub- 
acute suppuration 
of the middle ear. 
Recovery. 



The thrombus is rather adherent to the inflamed parts of the wall. 
It may be flat and grooved, so that the sinus remains permeable for the 
blood-current (parietal thrombosis), or the entire cross section of the 
sinus may be filled up by the thrombus (obturating or occluding throm- 
bosis, Figs. 105-109). 

The thrombi of the sinus sigmoideus and sinus transversus are usually 
fusiform in such a way that the thrombus is attenuated at both ends (Fig. 
105). An obturating thrombus, therefore, can only completely occlude 
the medial section of the sinus. The thrombi of the bulbus and vena 
jugularis are effusions of the affected parts of these vessels (Figs. 107-109). 
Otitic thrombosis of the sinus cavernosus is exceedingly rare. 

The color of fresh thrombi is dark red, of older ones grayish red, 
and of suppurative ones yellowish green. Thrombi are but seldom 
sterile. As a rule, they are infectious from the very beginning, micro- 



ENDOCRANIAL OTOGENIC AFFECTIONS 



305 



Fio. 108. 




Thrombus, natural size, removed by 
operation from the sinus transversus 
in extensive infectious thrombophle- 
bitis in the course of chronic suppura- 
tion of the middle ear. Recovery. 



Fig. 109. 



organisms being found along their entire length, but sometimes only in 
their obturated parts or at both ends. 

The color does not furnish any indication of the degree of infectious- 
ness. Fresh, deep-red thrombi may contain pure cultures of strepto- 
coccus pyogenes, while in old yellow or yellowish-green thrombi the 
micro-organism may already have been destroyed and the thrombi 
prove sterile both in cultures and animal experiments. 

The inflamed internal surface of the sinus is deep red in the early 
stage, brownish black or yellowish green in later stages. The external 
wall is thickened by fibrinous deposits, has a 
grayish-red or yellow color, and feels hard and 
coarsely elastic to the touch. In advanced 
stages of the inflammation it becomes discol- 
ored and friable. 

(c) Changes of the Surrounding Parts. — 
Very frequent concomitant manifestations of 
thrombophlebitis are pachymeningitis externa 
on the level of the affected venous sinus and 
on the external surface of the dura mater in the immediate proximity, 
callous thickening of the sinus wall, and accumulations of pus between 

the dura and the bone. The occurrence of pachy- 
meningitis interna has already been referred to. 

In some cases the cerebrospinal fluid under- 
goes changes. It becomes turbid, has sometimes 
a grayish discoloration, and shows minute fibrinous 
coagulations in the test-glass after standing undis- 
turbed for 6-24 hours. Microscopic examination 
reveals abundant mononuclear and polynuclear 
leucocytes, but no micro-organisms, the fluid prov- 
ing sterile both in cultures and animal experiments. 
There is no doubt that these cases, which represent 
about 10 per cent, of all forms of thrombophlebitis, 
are early stages of meningitis. A further proof of 
this being so is the presence of circumscribed acute 
cerebral oedema and hypersemia of the pia mater 
in all cases. 

The inflammatory changes of the bone itself 

extend in a number of cases from the middle-ear 

spaces to the region of the affected sinus, while in 

metastatic thrombosis the wall of the bone may 

be macroscopically unchanged. In all cases the affected parts of the sinus 

wall and the external surface of the dura are sharply demarcated against 

the normal surroundings. 

VI— 20 




Infectious thrombus, natural 
size, removed by operation 
from the vena jugularis interna 
in chronic suppuration of the 
middle ear. Recovery, a, con- 
tinuation of the thrombosis 
into the places of inosculation 
of the vena facialis communis, 
and b, into one of the thyroid 
veins. 



306 



THE DISEASES OF CHILDREN 



Fig. 110. 



The most frequent seats of insulated thrombophlebitis are the sinus 
sigmoideus, bulbus jugularis, and sinus petrosquamosus, in the order 
named. With a few rare exeptions, infection of the other venous sinuses 
of the auricular region can only occur by the inflammation spreading 
from the three sinuses named. Thrombosis may spread to all venous 
sinuses of the skull when the affection persists for a long time. The 
consequence may be that all the venous sinuses of the auricular region 
may become occluded, while the other sinuses contain fibrinous coagula- 
tions and organized connective-tissue layers, but still 
retain a central lumen as thin as a thread. Further- 
more, thrombosis may spread from the sinus sigmoid- 
eus or bulbus jugularis downward to the vena jugularis 
interna, the ventricle of the heart, and, in some cases, 
to all the small veins which communicate with the 
jugularis. 

The primary affection in these cases is thrombosis 
itself, while inflammation of the venous wall occurs 
only secondarily or not at all. In fully developed cases 
the thrombosed jugular feels like a thick resistant 
cord, which is distinctly palpable from without and is 
connected with its surroundings by fibrinous callosities 
(Fig. 110). This is usually complicated by infiltration 
of all deep glandular bundles of the neck, and the final 
result may be perforation of the vein and formation of 
extensive fetid abscesses. 

As has been shown by animal experiments, parie- 
tal sterile thrombi may be resorbed and the endothe- 
lium of the vein regenerated. In advanced cases heal- 
ing occurs through organized connective tissue in the 
thrombus, or the latter disintegrates from suppuration 
with consequent formation of an endosinous abscess. 
In cases where such an abscess is insulated against the 
vascular lumen by sterile obturating thrombus ends or 
by connective tissue, it usually perforates outward, 
forming a perisinous abscess. Suppurative meningitis develops less 
frequently. Should, however, the suppurative thrombus be insufficiently 
insulated against the vascular lumen, or not at all, the result will be that 
infectious parts of the thrombus, which have been liberated by the sup- 
puration, will find their way into the circulation; pus and micro-organ- 
isms will follow suit and lead to pyaemia, bacteremia, or toxaemia. 

Symptomatology. — Otitic thrombophlebitis presents highly charac- 
teristic manifestations which, barring a few rare exceptions, render the 
diagnosis possible at every stage of the disease. 




Vena jugularis interna, 
filled with thrombus 
masses and pus, extir- 
pated together with the 
bulbus. Natural size. Re- 
covery. The wall of the 
vein is considerably 
thickened by periphle- 
bitis and endophlebitis. 
The specimen is opened 
at two places, a and 6, 
exposing the thrombus 
masses which occlude 
the vein. Same case as 
Fig. 105. 



ENDOCRANIAL OTOGENIC AFFECTIONS 307 

The secretion in acute cases usually continues for a long time, but 
irregularly, it being alternately abundant, slight, or absent. In chronic 
cases the pus is fetid. 

There are earache and headache, especially in the occipital and 
mastoid regions, but in some cases these complaints are entirely ab- 
sent. The mind is clear. There are manifestations of the central 
nervous system, except in old cases which are already complicated by 
meningitis. In the latter cases there is increased cerebral pressure 
(headache, nausea, vomiting, restlessness, numbness, delirium, slow 
pulse, paralytic manifestations, plethoric veins of the fundus oculi). 
Active and passive motility of the head and neck are only diminished 
in cases where the phlebothrombosis has already spread to the bulbus 
or the internal jugular. There is often subicteric discoloration of the 
skin and sclerae. Fully developed icterus, however, occurs but very 
rarely. 

The temperature curve is of the pronounced intermittent febrile 
type and is a characteristic pathological symptom. After the tempera- 
ture has been normal for several hours, chills will occur, followed by a 
rapid rise of the temperature up to 104° or more. These attacks may 
occur only once or several times during the day, or they may be absent 
for several days together. The number of chills vary. There are cases 
in which there was but one attack at the onset of the sinus affection, 
while in others they may reach a total of twenty or more. 

In old and advanced cases of thrombophlebitis most patients give 
the impression of being very ill, while in the early stage or in chronic 
cases running an insidious course any particular general manifestations 
may be completely absent. These latter patients will apply to the clinic 
for outdoor treatment, as they and their friends fail to understand the 
importance of the chills, and febrile accessions of temperature may en- 
tirely escape them. It should be specially emphasized that patients 
suffering from such a grave affection need not necessarily present grave 
or any general symptoms at all. 

A simple thrombosis of the jugular may escape detection on pal- 
pation, as it can only be recognized by the plethora of superficial veins 
through a tender skin. The vessel can only be palpated at the ante- 
rior part of the neck as a thick cord in cases of purulent inflammatory 
thrombosis of the jugular with disintegration of the thrombus and with 
periphlebitis. 

Exophthalmos will occur in the case of very extensive thrombosis of 
the cerebral venous sinuses. 

Diagnosis. — The diagnosis of thrombophlebitis may be made at 
every stage of the disease, provided a reliable history of the disease and 
its course is available. 



308 THE DISEASES OF CHILDREN 

A correct valuation of the symptoms may render an early diagnosis 
possible, usually at the first examination. 

As in the other intracranial otitic affections, care should be taken not 
to obscure or destroy the clinical pathological picture described by the 
patient, which is usually done in a distinct and well delineated manner. 
In the absence of serious ear symptoms there is danger of erroneously 
referring chills, intermittent fever, and icterus to other diseases, such as 
influenza, central pneumonia, gastric and intestinal affections, etc., 
without considering the possibility of these symptoms emanating from 
the ear, or assuming that any sinus affections have already run their 
course. This would lead to the mistake of adopting a very dangerous 
waiting attitude, and, by the time that the medical examiners have 
agreed upon the fact that the pathological picture corresponds to an 
otitic complication, the favorable moment for a successful operation on 
the ear may have passed. 

On the other hand, the diagnosis may present great difficulties in 
cases with an incomplete, unreliable, or negative history, especially in 
regard to the variations of temperature. But a single sign may even 
in these cases suggest the presence of thrombophlebitis, such as restless- 
ness, ill appearance, subicteric discoloration, etc. 

A careful specialist will be guided by his experience, and find his 
suspicions confirmed in the great majority of cases when they come to 
operation. In those rare cases which run an afebrile course, the diag- 
nosis can only be made through a mastoid operation which is usually 
performed from the indications of an acute suppurative mastoiditis. 

For purposes of differential diagnosis in childhood, the following 
affections come in for consideration: (1) Uncomplicated cases of acute 
otitis media taking an atypical course; otitic descending abscesses with 
manifestations of retention. (2) Angina. (3) Pneumonia. (4) Malaria. 
(5) Typhoid. (6) Certain initial stages of acute infectious diseases. 
(7) Otitic meningitis or cerebral abscess. 

(1) These are always cases of beginning otitis media after the perfora- 
tion has occurred quite recently or a short time ago. Acute otitis media in 
childhood may set in with chills and intermittent fever, but the correct 
diagnosis can be made after a few hours, or, at the most, in one or two days. 
The fever either assumes a continuous type in a short time or entirely dis- 
appears; the chills are not repeated; abundant secretion is evacuated 
through the perforation. Should, however, in the further course of acute 
suppuration of the middle ear or in chronic cases, temperatures of 1013^° 
or more be reached, with the picture of intermittent fever, the clinical 
possibility of thrombophlebitis should be taken into consideration. 

In otitic descending abscesses with pus retention, high fever may 
suddenly set in which may have a slightly intermittent character. The 



ENDOCRANIAL OTOGENIC AFFECTIONS 309 

correct diagnosis follows from the absence of all other pysemic symptoms 
(chills, icteric or subicteric discoloration) and from the local signs of the 
descending abscess. 

(2) In cases of acute otitis media which are complicated by a cer- 
vical inflammation presenting pysemic symptoms, the differential diag- 
nosis may be embarrassing. The symptoms must be referred to the ear, 
if irregular or absent secretion coincides with the period of increased 
temperature or chills. In all these acute cases there are always simul- 
taneous manifestations of acute mastoiditis. 

(3) Pysemic symptoms in pneumonia are only present if the affection 
is of a severe type and has been very extensive from the first. In exam- 
ining the thorax and lungs, it will therefore be necessary to demonstrate 
correspondingly severe lesions. We cannot be content with uncertain 
pulmonary findings or with the assumption of a central pneumonia 
which cannot be demonstrated by auscultation. Pysemic symptoms in 
such cases are rightly referred to the ear or the regional venous sinuses. 

(4) The differential diagnosis as to malaria is established by micro- 
scopic examination of the blood. In all cases of septic thrombophlebitis 
the number of leucocytes are considerably increased, which is not the 
case in malaria. 

(5 and 6) The differential diagnosis as against acute infectious 
diseases, especially in children, demands adequate experience in the 
diagnosis of these diseases. In the absence of such experience, a compe- 
tent pediatrist should be called in for consultation. The early diagnosis 
of these infections is by no means so difficult as to prevent an immediate 
differentiation from otitic endocranial affections. 

(7) The differentiation of thrombophlebitis from simultaneously 
existing intracranial otitic diseases does not offer any difficulty in 
simple cases, since the former is characterized by the absence of any 
cerebral symptoms. But it should be remembered that meningitis or 
perforation of a cerebral abscess may set in with chills. The urgency of 
these cases does not permit of observing whether the fever is intermittent, 
as is the case in meningitis and cerebral abscesses, or whether it is con- 
tinuous. Besides, thrombophlebitis, meningitis, and cerebral abscesses 
may coexist. From a practical point of view, however, the differential 
diagnosis in such a case is only of subordinate value. The only require- 
ment is to diagnosticate the fact of there being an intracranial disease of 
an otogenic character, this being a sufficient indication for immediate 
operation. The exact differential diagnosis can then be made at the 
operation, as there will be no difficulty in recognizing even a combina- 
tion of several intracranial affections. Otological surgery here shares 
the same stand-point as general surgery. It is often necessary to be 
content with having localized a surgical disease sufficiently to permit of 



310 THE DISEASES OF CHILDREN 

instituting surgical measures at the right place, and the operative find- 
ings will furnish the exact diagnosis. 

Treatment of Otitic Thrombophlebitis. — Spontaneous healing of 
this affection is an exceptional occurrence. It may take place by resorp- 
tion of the pus and gradual obliteration of the affected parts of the sinus 
by connective-tissue formation if the affected thrombus in the sinus is 
protected at both sides by sterile thrombus masses. But even in these 
cases the more frequent course is for the infected contents of the sinus to 
perforate outward and for a perisinous extradural abscess to develop. 
But again there is some possibility of spontaneous resorption of such an 
abscess or its perforation into the mastoid, notably if the medial mastoid 
wall had been softened by suppuration or perforated by a fistula previous 
to the occurrence of sinus-phlebitis. 

Spontaneous healing of thrombophlebitis is so rare that it does not 
warrant rational conservative treatment. It is a surgical disease which 
offers no chances for recovery except by timely and adequate operation. 
If left to itself, patients usually succumb to the sequelae of the sinus- 
phlebitis, otogenic pyaemia, bacteraemia, or toxaemia, suppurative men- 
ingitis or cerebral abscess, or parenchymatous degeneration, notably 
of the large glands (liver, spleen, kidneys) and the heart muscle. As the 
danger of otogenic pyaemia is present in all cases of sinus-phlebitis, and 
as it is impossible to say in any particular case whether otitic pyaemia 
has already set in, it is necessary to carry out the operation to the same 
extent as in the case of developed otitic pyaemia. The object of the 
operation in the latter case is, of course, to eradicate the pyaemia, thereby 
preventing the further spreading of pus and the formation of metastatic 
abscesses. In thrombophlebitis without demonstrable metastases, with- 
out manifest pyaemia, however, the far more important object is to plan 
the operation in such a way as to prevent the formation of pus foci and 
metastases. Thus, it is often difficult to separate clinically otitic throm- 
bophlebitis from otitic pyaemia, but surgically such a separation is 
entirely out of the question. 

Plan of Operation 
The demands to be made upon an ear operation are the following: 

(1) Cleansing the pus focus as completely as possible and evacua- 
tion of the pus. 

(2) Reliable drainage of the pathological focus. 

(3) Exposure and opening of the affected venous sinus and removal 
of the thrombus. 

(4) Preventing the pus from entering the blood current. Where me- 
tastases are already present, the further spreading of the pus and forma- 
tion of new metastases should be prevented as far as lies in our power. 



ENDOCRANIAL OTOGENIC AFFECTIONS 



311 



The first demand is met by antrotomy in acute affections and by 
radical exposure of the middle-ear spaces in chronic cases. The surgical 
trauma is enlarged by two skin incisions in a posterior direction, permit- 
ting of an untrammelled survey of the affected regions of the ear and 
sinus. 

Previous to exposing the sinus and dura, it is advisable to remove 
the bone of the entire surroundings close to the level of the dura, so that 
the chisel in the opening process may not strike the sinus and dura in 
a right or blunt angle, but in the direction of a tangent (Fig. 111). This 

Fig. 111. 







Schematic representation of exposure of sinus and dura. D, dura mater; M, mastoid process; Ss, sinus 
sigmoideus. 

The correct technic is shown in Figs. 2, 3, 4. The bone is chiselled flat (2), so that the chisel may expose 
the sinus in the direction of a tangent (3) and the aperture thus made can be conveniently enlarged with the 
bone-forceps after lifting of the dura (4). The wrong technic is shown in Figs, a and b: Formation of a funnel- 
shaped opening (a), with the depth of the funnel directed toward the sinus. To reach the sinus wall involves 
considerable danger of injuring the sinus, as the chisel advances vertically toward the sinus. But, if the sinus 
wall has been reached, it will be found at the bottom of the funnel in such a small area that it cannot be con- 
veniently surveyed (fc). 



will avoid injury to the sinus and a highly unpleasant hemorrhage of 
the sinus in parietal thrombosis; at the same time it will facilitate the 
survey of the operative field and the technic of the subsequent exposure, 
as it is possible to remove the surrounding bone with the bone-forceps 
from the aperture made. When exposing the affected part of the sinus, 



312 THE DISEASES OF CHILDREN 

it is also necessary to allow of a survey of the healthy surroundings 
beyond the borders of the affected area. The presence of normal bone 
should not prevent the surgeon from exposing the sinus and exploring 
the seat of the disease, as long as there are signs of sinus-phlebitis. Pre- 
vious to removal of the bone, the connection between dura and bone 
and that between sinus wall and bone are severed with a blunt probe. 
This is effected by advancing the button probe from the exposed parts 
of the dura and sinus along the entire opening a few millimetres under- 
neath the bone. Mobilization of the dura and sinus will prevent acci- 
dental injuries with the bone-forceps. For the same reason it is advisable 
to use a bone-forceps with rounded points, the best being a bent Luer's 
forceps. This applies particularly to the exposure of the sinus itself. 
The exposure should not be limited to the sinus alone, but should also 
include the dura both before and behind the sinus. I am in the habit of 
proceeding in a thoroughly systematic way, starting from the exposed 
region of the sinus and proceeding first to the part of the dura behind and 
then to that in front of the dura. After that, the endocranial course of 
the sinus can be exposed. 

In following the sinus downward toward the bulbus venae jugularis, 
great care is required, as the lateral sinus wall is comparatively thin at 
that place and intimately adherent to the bone, even in the adult. The 
adhesions must, therefore, be very carefully loosened. It is also advis- 
able to protect the lateral wall of the sinus during the bone work by flat, 
fitted gauze strips, so as to prevent accidental injuries. Exposure in 
all the four directions named should continue beyond the affected area, 
until a rim of 5-10 mm. in width of normal sinus and normal dura is 
present in the field of operation, aside from the affected parts. The 
reason why the dura should be exposed both in front and behind the 
sinus is that most cases of thrombophlebitis, notably the advanced ones, 
are complicated by perimeningitis externa or even by extradural abscesses. 
Besides, it is technically simpler to construct a roundish aperture than 
one in the shape of a canal or groove that is adapted to the direction and 
width of the venous sinus. Technically, the bone-forceps is preferable 
to the chisel in the entire work. I have never seen any advantage accru- 
ing from the use of the saw, as the resulting pap-like mass interferes 
with the exact control of the operative field, it being often impossible, 
while at work, to determine whether the affected bone is completely 
removed. Besides, even employment of the greatest care in operating 
with the electric saw will not always prevent injuries to the sinus and 
dura. 

Osteoplastic is technically impossible, because, in the first place, 
we have to deal with a plate-like bone in the upper part of the sinus 
and in the dependent part of the sinus sigmoideus with the broad and 



ENDOCRANIAL OTOGENIC AFFECTIONS 313 

extensive mastoid process; and, in the second place, these osseous parts 
are purulently inflamed, and for that reason alone could not be utilized 
for osteoplastic purposes. 

The venous sinus being sufficiently exposed, it is necessary to examine 
its contents. The questions to be decided are : 

(1) Is there any thrombosis in the exposed area? 

(2) If so, is it parietal, merely narrowing the lumen of the sinus, or 
is it obturating, completely eliminating the lumen at a more or less 
circumscribed place? 

To decide these questions, it is necessary to open the sinus. Exami- 
nation with the aspirating needle does not furnish a reliable and posi- 
tive result, for the following reasons: If the end of the needle remains 
in the area of the thrombus, it will be impossible to aspirate any fluid 
contents, even in many cases of parietal thrombosis; when it is possible 
to aspirate blood, it is still doubtful whether there is a parietal throm- 
bosis or no thrombosis at all. It is only in those rare cases where pus 
can be aspirated that a diagnosis of obturating thrombosis can be made. 

A puncture of the exposed sinus with the scalpel, 1-2 mm. in length, 
will yield much better results. In normal cases the blood will be expelled 
in a jet; if the blood exudes slowly or appears in driblets, it is a sure 
sign of a stenosed lumen or parietal thrombosis. In the absence of any 
blood, the puncture is enlarged to 5-6 mm., and, as soon as the throm- 
bus becomes visible, it is detached from the wall of the sinus with a 
blunt instrument. If there is still no blood, there is sure to be an obturat- 
ing thrombosis. 

The presence of the thrombus having been demonstrated, its re- 
moval follows next. Parietal thrombi can but very imperfectly be 
removed with instruments, if at all. The sinus puncture is prolonged to 
8-10 mm. A sharp spoon is carefully introduced with its concavity 
toward the lateral wall of the sinus, so that, when it is withdrawn, 
none but thrombi attached to the wall will be removed. In obturat- 
ing thrombosis the lateral wall of the sinus is dissected longitudinally 
in an upward direction; the thrombus is detached from the wall and 
its upper pointed end developed. This end usually extends far into 
the sinus (Fig. 105), and there is always considerable hemorrhage in 
fetching up this end piece. By gentle pressure with an iodoform wick 
carrier the hemorrhage is immediately arrested. The next step is to 
divide the lateral sinus wall in the direction of the lower end of the 
thrombus, the extraction of which is again attended with hemorrhage 
if the bulbus vense jugularis still contains flowing blood. This hemorrhage 
is arrested by advancing an iodoform wick into the lumen of the sinus. 
The loss of blood will only be slight in the hands of an experienced oper- 
ator, as the hemorrhages are expected after mobilization of the ends of 



314 THE DISEASES OF CHILDREN 

the thrombus and the iodoform wicks would be held in readiness. In 
parietal thrombosis the lateral wall of the sinus is left in situ after 
the division. In obturating thrombosis the lateral wall of the sinus is 
resected as far as there are any inflammatory changes, after the throm- 
bus has been removed and the hemorrhage arrested. If the medial wall of 
the sinus is smooth and glistening and shows a gray discoloration, the oper- 
ation on the venous sinus is at an end. The wound is covered with iodo- 
form wicks and the skin flaps are fastened over them with a bridle suture. 
Should the medial wall of the sinus be dull, fragile, and of grayish-yellow 
or greenish color after resection of the lateral wall of the sinus, it is a 
positive sign of the phlebitis having spread to the medial sinus wall. This 
would point to the probability of the presence of pachymeningitis and en- 
cephalitis (meningo-encephalitis) . In order to decide positively whether 
there is pachymeningitis, requiring the division of the dura and opening 
of the intradural spaces, a lumbar puncture must be made. Full details 
on this subject are contained in the chapter on pachymeningitis interna. 

BTJLBUS THROMBOSIS 

Inflammation of the bulb us of the vena jugularis may take place 
in three ways: 

(1) By a thrombosis of the sinus sigmoideus spreading downward 
to the bulbus jugularis and the vena jugularis interna. 

(2) By continuous or metastatic spreading of the ulcerative process 
through the fundus of the tympanic cavity to the vena jugularis. Direct 
extension of the suppuration occurs preferably in those cases where the 
bulbus, which is located in the fossa jugularis, is separated from the 
tympanic cavity by a thin bony layer, or where in consequence of osseous 
gaps there is no complete separation at all between the bulbus and the 
hy potympanum . 

(3) By the extension of a pus focus in the mastoid. This occurs 
in cases where the fossa jugularis and the hypotympanum are sepa- 
rated by a bony layer which, although very broad and sometimes up 
to 6 mm. thick, is permeated by numerous air spaces which commu- 
nicate with the air spaces of the mastoid and are promptly attacked in 
suppurative mastoiditis. Under such circumstances there is the same 
danger of infection for the bulbus which exists for the sinus sigmoideus 
in acute mastoiditis. 

Symptoms. — Like the thrombus of the other venous sinuses, that 
of the bulbus is associated with clinical manifestations of otitic pyaemia. 
There are no positive clinical signs, however, which admit of an exact 
clinical diagnosis of bulbus thrombosis before the operation. 

It may, however, be said in a general way that bulbus thrombosis 
should be thought of in cases of chronic suppuration of the middle ear 



ENDOCRANIAL OTOGENIC AFFECTIONS 315 

with far-advanced destruction of the middle ear, and especially in cases 
of cholesteatoma of the hypotympanum and chronic suppurative mastoi- 
ditis. In most chronic and all acute cases, however, the operative find- 
ings alone permit an exact decision. The diagnosis of bulbus thrombosis 
is very probably correct if, after exposure of the sinus, the inflammatory 
changes and the thrombosis are still demonstrable in that part of the 
sinus sigmoideus which is deflected in an anterosuperior direction. A 
fully developed bulbus thrombosis may be positively diagnosticated if 
the jugularis interna is found to be empty, or if the blood exudes from 
the peripheral end of the jugular with slight pressure or only in drops. 
The vense condyloidese, the sinus petrosus inferior, and sometimes the 
terminations of the vertebral veins inosculate below and in the neigh- 
borhood of the bulbus jugularis. If the thrombus of the bulbus has 
spread to the inosculations of those veins, or perhaps to the veins them- 
selves, the jugular is entirely deprived of any blood supply, and the pe- 
ripheral end of the jugular, when opened, is found to be empty. Should 
the inosculations be still uninvolved, then it is merely the principal arm 
of the affluent blood that has been injured by the bulbus thrombosis, 
so that the evacuation of the blood from the sinus sigmoideus into the 
jugularis interna is rendered difficult or impossible. In such a case there 
is still flowing blood in the vena jugularis interna, which, however, 
exudes with but slight pressure and in small quantities. 

Treatment. — There are two methods of treatment: (a) the surgical 
exposure and opening of the bulbus, and (b) the surgical drainage of the 
bulbus. 

Grunert exposes the bulbus after resection of the mastoid apex, 
free exposure of the sinus sigmoideus, and ligature of the jugular. He 
follows the sinus sigmoideus up to the bulbus and after detaching the 
surrounding muscles (sternocleidomastoid, digastricus, splenius capitis, 
and rectus capitis lateralis) exposes the bulbus from behind, gradually 
removing the osseous cover. This may necessitate the resection of the 
transverse process of the first cervical vertebra. According to this 
method the posterior surface of the bulbus presents itself first. This, 
however, involves the great danger of injuring the facial nerve, and, 
besides, a satisfactory exposure is impossible if the bulbus has developed 
strongly upward. 

Tandler combines the retro-auricular skin incision with the ligature 
of the jugular, inverts the sternocleidomastoid backward, and exposes 
the bulbus in a perfectly satisfactory form without any danger to the 
accessory and facial nerves. 

Piffl's method consists in exposing the bulbus, starting from the 
auditory canal, by removing the inferior wall of the osseous auditory 
canal and of the fundus of the tympanic cavity, the exposure commencing 



316 THE DISEASES OF CHILDREN 

at the head of the bulbus istelf. By further removing the soft parts 
and the bone, the exposure may be extended to the jugular. 

Voss starts from the medial wall of the bulbus. 

In order to obtain reliable drainage, the sinus sigmoideus may be 
followed over the lower knee anterosuperiorly up to the bulbus. By 
removing the wall of the sinus, the vast extensive cross-section of the 
sinus will admit of liberal access to the contents of the bulbus, which 
may now be removed along with the wall of the bulbus with the aid of 
the sharp spoon. This can be done without any difficulty. Reliable 
and sufficient drainage of the bulbus may be effected near the auricular 
wound by introducing iodoform wicks, while a reliable drainage of the 
bulbus may be effected through the jugular itself by means of the skin 
fistula of the jugular which I have devised. In most cases I have ob- 
served, drainage has proved satisfactory except where fetid thrombosis 
and suppuration of the bulbus rendered it necessary to remove completely 
the lateral osseous wall after resection of the mastoid. I have never 
found it necessary, however, to resect the transverse process of the atlas. 

Clinical Course and Prognosis. — After drainage has been established, 
the secretion of pus from the bulbus usually continues for six to ten 
days. The first change of bandage should, therefore, take place as early 
as the second or third day after operation, and repeated daily in order 
to prevent retention. 

The prognosis does not differ from that of otitic thrombophlebitis 
and will be described under that head. 

LIGATION OF THE JUGULAR. SKIN FISTULA OF THE JUGULAR 

In order to prevent the spreading of pus in otitic thrombophlebitis 
and pyaemia, Zaufal recommended, in 1889, the ligature of the vena 
jugularis interna of the healthy side. His idea was that this vein was 
the principal centripetal channel for conveying the contents of the 
infected auricular venous sinus, and that, consequently, its ligation was 
the best way to prevent spreading of pus, and that such spreading would 
be arrested if it had already set in. The theoretical foundation of this 
operation is not free from objections. Pus and bacteria may be conveyed 
from the auricular region by other vessels, aside from the jugularis 
interna, as for instance the vense condyloideae and the vertebral veins, 
the latter anastomosing in nearly all cases with the deep as well as with 
the superficial cervical veins. Furthermore, pus may be spread by retro- 
grade conveyance through the sinus transversus, the sinus sigmoideus, and 
the jugular of the healthy side. The possibility of conveying pus in a 
direction contrary to that of the blood current is explained by the fact 
that the venous blood flows intensely only in the axial part of the vessel, 
while there is but slight movement in the proximity of the walls. At such 



ENDOCRANIAL OTOGENIC AFFECTIONS 317 

places where the vessel suddenly changes its direction (knee of the sinus, 
bulbus), part of the current may be completely arrested, there may be 
-whirls, and, in some parts at least, actual reversion of the current. 

It is not surprising, therefore, that the ligation of the vena jugularis 
interna as a preventive of metastasis is not always successful, and that 
metastases do often occur in spite of the ligature. Furthermore, metasta- 
ses may have existed before the jugular was ligated and new metastases 
may develop from the old ones. The unfavorable results were further 
increased by the fact that Zaufal's suggestion was misunderstood. The 
idea was entertained that the ligation of the jugular was a sufficient sur- 
gical measure for the treatment of otitic pyaemia, so that the exposure 
and drainage of the auricular pus focus were either omitted altogether, 
not carried out in time, or done imperfectly. 

In conjunction with surgical treatment of otitic pyaemia, ligation 
of the jugular is a very valuable and beneficial proceeding. 

However, I have substituted for this method the skin fistula of 
the jugular, which is made either primarily at the time of operation 
or secondarily from one to three days after the operation. The neck 
of the patient is stretched by placing a small cushion underneath it 
and the head is turned toward the healthy side. An incision is then 
made on the affected side in the middle third of the neck, exposing 
the jugularis interna. The incision is about 4 cm. in length and is 
made at the anterior border of the sternocleidomastoid. After resection 
of the platysma and moving the musculo-cutaneous nerve to one side, 
the muscle is bluntly dissected free and rolled away in a postero-exte- 
rior direction. This brings into view the lateral wall of the jugularis 
interna, covered with a vascular sheath. The latter is either bluntly 
divided at its posterior circumference or longitudinally intersected over 
a hollow probe. The vein is now dissected free by a circular incision. 
Should the vena facialis communis appear in sight and interfere with 
convenient mobilization of the jugular, it is doubly ligated and cut 
through between the two ligatures. This procedure will not be neces- 
sary if the ligature of the jugular can be effected in such a way that the 
inosculation of the vena facialis communis will lie centrally from the 
ligature of the jugularis. 

If flowing blood should be found in the jugularis interna, the fistula 
should not be made for the moment. The vessel is doubly ligated, cut 
through between the two ligatures, the long ligature threads being con- 
ducted outward. As a rule, the ligature at the peripheral end of the 
vein may be removed in twenty-four hours without any danger of hem- 
orrhage, after which the skin fistula may be proceeded with. The liga- 
ture of the central part of the vein can be removed in from eight to ten 
days, provided no complications set in. 



318 THE DISEASES OF CHILDREN 

Should the vena interna be found to be empty and the wall of the 
vessel unchanged, it is advisable to place the fistula in the upper angle 
of the cervical wound, so that the natural drainage tube need not be 
unnecessarily long; at the same time, it will prevent stagnation of the 
secretion. Should the jugular contain thrombi or pus and the wall show 
inflammatory thickening, it will be necessary to expose the jugular 
further centrally, until a wall of normal appearance has been reached. 
This may further lead to the necessity of temporarily resecting part of 
the sternocleidomastoid. Should the phlebitis extend very low down, it 
may even be necessary temporarily to sever the muscle from its inser- 
tion at the sternum. On the other hand, I never found it necessary to 
resort to the temporary resection of the clavicle (Grunert) . The central 
ligature is made as low down as possible, the peripheral lumen of the 
jugularis remains open, the open cross section of the jugular is enlarged 
by a longitudinal incision through the wall, about 1 cm. in length, and 
the vena jugularis is fixed by interrupted sutures in the skin wall along 
the more or less oval aperture which has been provided. In this way 
the contents of the vein are drained outward for the entire length of the 
peripheral part of the jugular vein, and the drainage of the bulbus is 
effected through the skin fistula of the jugular. 

In suppurative periphlebitis of the jugular, adhesions between the 
vein and the surrounding connective tissue have been observed, likewise 
infiltration of the soft parts of the neck. In such cases extirpation of 
the jugularis interna (Fig. 110) and direct drainage of the bulbus are the 
indicated measures. 

The lumen of the jugular is kept open by wicks which are inserted 
in an upward direction. In other respects the cervical wound may be 
closed. 

In all cases of diagnosticated otogenic thrombophlebitis and pyaemia, 
I ligate the jugular as a preliminary step to the ear and sinus operation. 
The second step in acute cases is antrotomy and resection of the mastoid, 
in chronic cases the radical exposure of the middle-ear spaces. The 
third and last act consists in the exposure and opening of the affected 
venous sinus, including the bulbus if necessary, and in the removal of 
the thrombi. 

By planning the operation in this way, the exclusion of the jugular 
offers great advantages. It is an improvement in the sense of Zaufal's 
original suggestion, because the exclusion of the largest centripetal 
blood canal overcomes the danger of a general infection and metastases 
in a large number of cases. 

Brieger recommends the ligation of the jugular in cases where the 
pathological focus cannot be completely reached from the auricular 
wound, or where the sinus furnishes negative findings and the existing 



ENDOCRANIAL OTOGENIC AFFECTIONS 319 

pyaemia must necessarily be referred to thrombosis of the jugular. Kuem- 
mel believes that the manipulations necessary in ligating the jugular may 
dislodge parts of the thrombus in the jugular and may be the cause of 
pulmonary metastases. 

Ligation of the jugular as a preliminary step to operations on the 
ear and sinus protects against the danger of parts of the infected throm- 
bus being mobilized and carried into the circulation during the act of 
removing the bone which involves an unavoidable trauma of the sinus. 

If the diagnosis of thrombosis is only made at the operation, the 
latter is suspended until the jugular has been ligated. This arrange- 
ment makes provision by a single operation for everything that is neces- 
sary for the surgical treatment and healing of otitic pyaemia. The 
ligation of the jugular, the skin fistula of the jugular, the continued 
exposure of the affected sinus until healthy parts have been reached, 
the timely opening of the venous sinus, and the removal of the throm- 
botic masses, protect the patient from the danger of having to undergo 
several or renewed operations in case the original incomplete proceed- 
ing (insufficient exposure of sinus, impractical exposure of the affected 
parts, omission of excluding the jugular) should not meet the require- 
ments of the case. Otogenic pyaemia causes exceedingly rapid degener- 
ation of the heart muscle and the large glands. Each fresh anaesthesia, 
each fresh operation, favors the progress of the degeneration, aside 
from the fact that subsequent completion of the operative measures is 
too late in most cases and unable to prevent a fatal issue. 

It is admitted that a mastoid operation may be satisfactory where 
there is no highly virulent infection and in cases of sterile thrombosis, 
but it is impossible to determine the virulence of the pyogenic factors 
or the infectious properties of the thrombus before operation. The idea 
of doing a simple operation and resorting to exposure and opening of the 
sinus and ligation of the jugular vein, in case the original operation 
should prove insufficient, is a mistake, inasmuch as it will only answer 
in a small number of cases of slightly infected or sterile thrombi the 
outcome of which will depend upon a mere accident. In most cases 
this waiting attitude or "fractional operating" will prove disastrous, 
because subsequent operations which may be required by persisting 
pyaemia are usually in vain. The extent to which the operative find- 
ings can influence our decision is limited to the question of the size of 
the exposure of the sinus and bulbus regions. 

PYEMIC METASTASES 

Otitic phlebothrombosis may be the starting-point of otitic pyaemia, 
bacteraemia or toxaemia. Pyaemia will occur from pus and micro-organ- 
isms entering the circulation from the original otogenic focus in the 



320 THE DISEASES OF CHILDREN 

venous sinus, causing suppurative metastatic inflammation by infec- 
tious deposits in various parts of the body. 

According to the localization of the metastases, the following forms 
of otitic pyaemia have to be distinguished: (1) the cranial form, (2) 
the thoracic form, (3) the abdominal form, (4) metastases in the bones, 
muscles, and joints. 

Of course, there are often mixed forms, but clinical experience 
causes us to adopt the above division, the more so as it is also of impor- 
tance for the prognosis. 

In cranial otitic pyaemia there are metastases in the bone itself, 
pyaemic cerebral abscesses, pachyleptomeningitis or pachymeningitis 
interna, metastatic suppuration of the cranial bones, cavities of the eye, 
or accessory cavities of the nose. Generally speaking, this form of pyaemia 
is rare. The cases of cerebral abscess which have been observed in otitic 
pyaemia conform to the interpretation that the abscess has not occurred 
by metastasis, but by direct spreading of the pus focus from the venous 
sinus to the endocranium. 

Pachyleptomeningitis in cases of otitic pyaemia is, unfortunately, 
not a rarity. In one-half of all fatal cases due to otogenic pyaemia the 
cause of death is suppurative meningitis. A small number of these are 
of metastatic origin, but the majority occur by direct spreading or 
perforation of the endosinous pus focus. On the other hand, a small 
number of positive cases of metastatic pachymeningitis interna have 
been reported, in which the inflammatory foci of the endodural surface 
must be looked upon as metastases of the pus focus in the sinus. 

The thoracic form of pyaemia is characterized by the metastatic pul- 
monary abscess. This form of otitic pyaemia is of frequent occurrence. 
There may be one single abscess, but in many cases there are a large 
number of them. Both lungs may be attacked by the suppuration. 
The smaller bronchi as well as the larger bronchi of the affected pulmo- 
nary region will also be invaded in a relatively short time. With per- 
foration of the abscess there will be suppurative pleurisy, suppurative 
bronchitis, and empyema of the lungs. Metastatic inflammation of the 
heart and pericardium are by no means rare in long-persisting pyaemia. 

Pyaemic metastases in the kidneys are also rather frequently ob- 
served, while abscesses in the liver and spleen as well as metastatic 
suppurative peritonitis or cystitis are very rare. 

Muscle metastases are oftener found in the regions of the neck, 
shoulders, and buttocks than in other parts of the body. I have often 
observed large abscesses of the muscles in the region of the scapula, 
especially the deltoid, but of course abscesses may occur in any other 
muscle. In most cases the muscle abscesses commence after the type 
of phlegmons, suppurative disintegration starting in the muscle sub- 



ENDOCRANIAL OTOGENIC AFFECTIONS 321 

stance itself. If the pus has perforated through the fascia, widely rami- 
fied descending or multiple abscesses may develop. I once saw a com- 
plicated abscess formation of the perineum which had started from a 
suppurative otitic metastasis of the glutseus medius muscle. 

Abscesses of the muscles of the abdomen and extremities usually remain 
well localized, and are soon recognized by the circumscribed swelling and 
reddening of the skin. 

Concerning suppurative metastases in the bones, the femur, scapula, 
tarsus, humerus, carpus, and the phalanges may be mentioned. In one 
case I observed suppurative metastasis in the ribs, sternum, and third 
cervical vertebra. Suppurative inflammation of the joints themselves 
is fortunately rare. I observed a case in which the metastasis ran a 
five weeks' course, starting with an extensive metastasis of the left knee- 
joint and spreading to the right knee-joint, the right astragalus, the 
right carpus, later to the left carpus, and finally to the sternoclavicular 
articulation. 

A ten-year-old boy was taken ill with otitic otogenic pyaemia follow- 
ing an acute scarlatinal otitis. A metastatic coxitis developed in the right 
hip-joint, which terminated with ankylosis and shortening of the leg. In 
the course of the disease there developed an osteomyelitic abscess in the 
upper part of the femur of the affected side and in the large trochanter. 

Symptoms and Course of Metastases 

Symptoms. — The formation of metastases is principally recog- 
nized by the continuance of the pysemic general manifestations (inter- 
mittent fever, chills, icterus) after the pus foci of the ear and venous 
sinus have been surgically removed. Local pains often point to the place 
of the metastatic inflammation, but patients are liable to commit consid- 
erable errors in their localization. Thus, the patient mentioned above, 
suffering from metastatic coxitis, always referred his pain to the lower 
end of the femur, and it required a thorough radiographic examination 
to clear up the real seat of the disease. Metastases in the muscles are 
more correctly localized ; here, again, the seat of the inflammation is usu- 
ally recognized without any difficulty. Should there be pain in the orbit, 
it is of the utmost importance to test carefully the functional capacity of 
the eye muscles. 

Metastases in the accessory cavities of the nose may begin and end 
without causing any pain. The suspicion of their presence is aroused b} r 
acute occlusion of one side of the nose, due to swelling of the lower or middle 
turbinated bone or by spontaneous secretions. The situation is cleared 
up by a thorough examination of the nose and its accessory cavities. 

Pulmonary abscesses, too, may exist without giving rise to any 
symptoms, as they may only cause trouble after pleurisy has developed 

VI— 21 



322 THE DISEASES OF CHILDREN 

in the region of the abscess. Irregularities of respiration demand careful 
examination of the lungs. Suppurative abscesses which are situated 
near the surface of the lungs cause the thorax of the affected side to 
remain distinctly behind in the act of respiration. 

Abdominal metastases are recognized by the distention of the 
abdomen. There is tension and hardness of the abdominal wall, and 
often there is retention of urine at an early stage. 

X-ray examination for establishing and localizing pyaemic metas- 
tases cannot be too urgently recommended. 

Diagnosis. — The diagnosis of metastases in the muscles and joints 
usually presents no difficulties. Their presence is indicated by local 
pain and the continuance of pyaemic manifestations. Muscle abscesses 
can be palpated without great difficulty. In order to diagnose metas- 
tases in the articulations and long tubular bones, it is sometimes neces- 
sary to make repeated X-ray examinations. As to the diagnosis of 
metastases of the thoracic and abdominal viscera, the text-books of 
internal medicine should be consulted. 

If the changes of the ear itself and the regional pathologic mani- 
festations should not sufficiently explain the continuance of the pyaemic 
conditions, it will not do to be content with the vague assumption of 
the presence of pyaemia. Metastases should be energetically looked for 
at an early stage, not forgetting the infrequent ones (spleen, liver, peri- 
tonitis and cystitis, etc.). 

Treatment. — In young patients, and especially in children, there is 
a favorable possibility of suppurative metastases completely healing 
without operation. I saw an ideal recovery from a metastatic endo- 
and pericarditis in a boy of four years; in a girl eight years of age 
there was spontaneous involution of a pulmonary abscess, — that is, heal- 
ing of a pulmonary infarction. 

Among the internal remedies the following may be mentioned: 
Nucleic acid (5-20 c.c. subcutaneously) , nucleic sodium and nucleo- 
gen — Rosenberg (2 or 3 tablets daily), argentum colloidale and elec- 
trargol (5-20 c.c. intravenously or per rectum). In the period of high 
fever, cold packs are indicated; liberal fluid nutrition (if necessary by 
nourishing enemas) and inunction with unguentum Crede will be 
useful. In cases of a septic character, tentative injections of strepto- 
coccus serum and auto vaccination are justified. The streptococcus 
injection, however, is only applicable if streptococcus infection has been 
demonstrated, 1-4 injections of 5-10 c.c. each being made at intervals 
of 2-3 days. 

It is always advisable to open the metastatic focus as early as pos- 
sible, except in metastatic osteomyelitis, where the full development of 
the abscess should be awaited; otherwise it might become necessary to 



ENDOCRANIAL OTOGENIC AFFECTIONS 323 

resort to an unnecessarily extensive exposure of the marrow in the long 
tubular bones. It might also happen that, in spite of extensive evacua- 
tion of a part of the bone, a second or even third operation will become 
necessary owing to the continuance of fever and pain. In metastatic 
abscesses of the knee-joint, repeated puncture of the joint usually leads 
to complete recovery with good motility. Metastatic coxitis, however, 
always leads to ankylosis. 

Course of Temperature in Otitic Pycemia 

Otitic pyaemia is characterized by intermittent fever. In thoroughly 
characteristic cases the rise of temperature from normal or subnormal 
to very high degrees of fever occurs in a very short time. The high tem- 
perature is maintained for some time and recedes shortly before a fresh 
accession takes place. In many cases there is only one accession in 24 
hours, in others there are several in the same time. It may be said in a 
general way that the number of accessions increases with that of the 
chills. In some cases there is only one characteristic chill at the begin- 
ning of the pyaemia, which is suddenly followed by fever temperature. 
In these cases the intermittent type of the fever is not very distinctly 
apparent. There are neither declines to the normal nor very high eleva- 
tions. It may be said, from the study of a large number of temperature 
curves, that there is already ground for suspicion of otogenic pyaemia 
in cases where the lowest temperature in the course of a day is 97.7° or 
less, and the highest 100.95° to 101.5°, amounting to a difference of at 
least 2.25°. It is a dangerous symptom for the intermittent type to 
change to the continuous in the course of the disease, as the occurrence 
of continually high fever following in the wake of intermittent fever 
is to be looked upon as an indication that direct spreading of pus has led 
to a metastatic suppurative meningitis. 

Continuous fever lasting for a day or more at moderate height or 
normal temperature may be followed by a fresh rise of temperature 
caused by the development of a fresh metastasis. After recovery has 
taken place, intermittent fever usually occurs for a few days longer than 
the local pathological manifestations. 

Postoperative fever in otogenic pyaemia deserves particular atten- 
tion. The most favorable course is decrease of fever by lysis in such a 
way that, on the fifth or sixth day after operation, the temperature will 
be normal and remain so. With the occurrence of new metastases after 
operation, intermittent fever will of course continue, and on the occur- 
rence of new chills there will be characteristic and important variations 
in temperature. 

Return of temperature to normal immediately after the operation 
admits only exceptionally of a favorable interpretation, and that is 



324 THE DISEASES OF CHILDREN 

when the pysemic process is at once arrested and cured with the opera- 
tion. In that case the temperature may at once return to normal and 
remain so. In most cases, however, where normal temperature returns 
immediately after the operation or on the following day, it means a 
collapse temperature and is to be looked upon as unfavorable. It is 
explained by a further loss of strength the patient has undergone from 
the operation, and an appreciable rise will occur in the next two or three 
days; and on the fifth or sixth day, at a time when in favorable cases 
normal temperature is being attained, high pysemic fever accessions will 
again prevail. In unfavorable cases the intermittent type will sooner 
or later change into continuous fever. In cases with fatal termination 
there is usually a sudden decline of temperature shortly before death, 
associated with an exceptionally high pulse frequency. 

Pulse and respiration are accelerated in all cases of otogenic pyaemia, 
160-180 pulse-beats being no rarity in young patients. The pulse accel- 
eration is often still present for several weeks after the pyaemia has run 
its course. 

It is important to observe the respiration, because its abnormal be- 
havior is often a sign of a pulmonary abscess. As to the details of 
this phase the text-books of internal medicine should be consulted. 

Postoperative Prognosis of Otogenic Pyoemia 

The pathological material, consisting of 96 cases which I have 
observed and operated upon, shows a mortality of 16 per cent. 

The mortality of otogenic pyaemia is, therefore, higher than that 
of extradural abscess and chronic suppuration of the labyrinth. It is 
lower than in acute diffuse suppuration of the labyrinth, abscess of the 
temporal lobe or cerebellum, or infectious suppurative meningitis. Com- 
parison of the present mortality of 16 per cent, with that of 80-90 per 
cent, in the pre-operative era will show the advantages afforded by 
exact indications and systematic planning of the operation. 

Will it be possible to reduce the mortality still further? 

To decide this question it is necessary to study the autopsy findings 
for the changes from which the unfavorable cases died. 

Some eight years ago I compiled the autopsy findings on the occa- 
sion of a comprehensive paper, showing the following causes of death: 

(1) Local changes of the ear in cases where the pus focus in the 
ear and venous sinus failed to heal. The principal contributors to this 
group are the formerly very frequent cases in which otitic pyaemia and 
thrombophlebitis were not accurately diagnosed and consequently could 
not be adequately and promptly operated upon. 

(2) Pyaemia or sepsis with far-advanced degeneration of the peri- 
cardium and the large glands (spleen, liver, kidney). 



ENDOCRANIAL OTOGENIC AFFECTIONS 325 

(3) Non-diagnosed metastases which had led to fatal affections. 

(4) Infectious suppurative meningitis and acute encephalitis. 

The second group comprises all those cases in which pyaemia had 
run a very chronic course and there was the necessity of repeated opera- 
tive interference ; furthermore, those cases in which the affection showed 
rather a septic character or where the power of resistance had been 
lowered by other affections. 

The third group contains cases with suppurative metastases in 
unusual situations which could not be easily traced (spleen, liver, and 
kidney abscesses with purulent pyelonephritis). In these cases there is 
the danger of the metastases remaining undiscovered for a long time, 
until the abscesses perforate, causing death by extensive suppurative 
disintegration. 

The percentage of cases which are complicated by suppurative 
pachyleptomeningitis is still considerable to this day. In spite of timely 
diagnosis, exact indication, and efficient operation, we are in a certain 
number of cases unable to prevent the development of meningitis. 

With these considerations it is possible to furnish a fairly clear 
answer to the question as to whether we may be able still further to 
reduce the mortality of these cases. Exact clinical examination, leading 
to a correct diagnosis at an early stage, is of great importance. If, 
based upon this diagnosis, operation is performed sufficiently early, and 
to a sufficient extent from the first, there is no doubt that the percentage 
of cured cases will be raised. The number of those cases in which patients 
have succumbed to degeneration of the pericardium and the large glands, 
owing to repeated operative measures, will be reduced by planning the 
operation in a systematic manner and carrying it out at one sitting. 

III. OTITIC SEROUS MENINGITIS 

Serous meningitis occurs more frequently in acute inflammation 
of the middle ear or labyrinth than in chronic cases. Many of them 
present a definite pathological picture, others resemble the early stages 
of acute suppurative or tuberculous meningitis. The affection is far 
more frequent in children than in adults. 

Anatomy. — The principal sign is the inflammatory increase of the 
cerebrospinal fluid with consequent elevation of the intracranial pressure. 
The meninges are hypersemic, highly osmotic, and in long-existing cases 
gray or grayish-white discolored in circumscribed places. There is in 
many cases early cedematous swelling of the cerebral surface leading to 
acute encephalitis. The changes usually extend over the entire cerebral 
surface, often involving the spinal meninges. It is only rarely that the 
meningitic changes remain circumscribed and in close topical relation 
to the affected ear, but it is just in these cases that there is usually serous 



326 THE DISEASES OF CHILDREN 

meningoencephalitis as a preliminary stage to acute suppurative or 
tuberculous meningitis. 

Complete healing occurs in uncomplicated cases. The quantity 
of cerebrospinal fluid is reduced to normal, and the inflammatory mani- 
festations of the cerebral meninges and of the brain completely disappear. 
If serous meningitis is the precursor of purulent meningitis, the suppura- 
tion will follow the acute stage either immediately or only after a pro- 
longed existence of the original affection. 

Cerebral manifestations capable of simulating meningitis may occur 
at the onset of acute otitis media previous to the perforation of a sup- 
purative exudate through the tympanic membrane. This symptom, 
for which the term " meningismus " has been proposed, will disappear 
as soon as the pus secretion from the middle ear commences after para- 
centesis. 

Symptoms. — The principal symptom of serous meningitis consists 
in early delirium, disturbance or loss of consciousness. The latter may 
persist for days. As a rule, there are early lagophthalmos and moderate 
rigidity of the neck. The fundus of the eye is unchanged. Should there 
be pathological changes, we have to deal not with serous meningitis 
proper, but with a serous preliminary stage of suppurative meningitis. 
Vomiting in serous meningitis is rare; slow pulse will persist for a long 
time. 

It is a carious fact that nutrition of the patient will succeed fairly 
well by careful introduction of fluid food, in spite of disturbed conscious- 
ness. At the climax of manifestations there may be incontinence of 
urine and faeces. There are no convulsions or paralysis of the extremi- 
ties. The latter are relaxed, and the motor innervation is weakened, but 
not entirely suspended. 

Diagnosis. — The exact diagnosis and differentiation of serous men- 
ingitis as against the other forms of meningitis follow from the symptoms 
as explained above and from the findings of lumbar puncture (see p. 
355). The cerebrospinal fluid flows off under increased pressure and 
is clear and sterile both microscopically and in cultures. Standing 
undisturbed in a test-tube for six to twenty-four hours will not cause 
any coagulation. 

The course of serous otitic meningitis is nearly always favorable. 
The manifestations gradually diminish, and upon return of conscious- 
ness there is rapid recovery. 

The question of treatment of serous otitic meningitis is not yet 
quite settled. However, immediate energetic evacuation of the puru- 
lent exudate in the middle-ear spaces is unquestionably indicated at 
the onset of meningitic manifestations. With a still imperforate tym- 
panic membrane, free paracentesis will often be attended with good 



ENDOCRANIAL OTOGENIC AFFECTIONS 327 

results. Should the manifestations show no abatement in the course of 
twenty-four hours, antrotomy and lumbar puncture are indicated in 
acute suppuration of the middle ear. In chronic cases lumbar puncture 
must be preceded by the radical operation. Opening of the dura is only 
indicated if the local suppurative inflammation of the temporal bone can 
be continuously followed up to the dura and the external surface of the 
dura shows inflammatory changes. In the absence of circumscribed 
changes the mere exposure of the dura will suffice without incision. 
The first change of bandage is made twenty-four hours after operation, 
when in favorable cases the tension of the dura will already be diminished. 

Should increased tension persist in spite of lumbar puncture, a 
longitudinal incision is made into the dura, taking care not to injure 
any of the larger dural vessels. As a rule, the cedematous brain will at 
once protrude into the incision, so that the otherwise desirable insertion 
of drainage strips into the intradural space will succeed only in excep- 
tional cases. The dura being incised, any further lumbar punctures 
should be avoided. If the dura is not incised, lumbar puncture should 
be repeated at intervals of five days, evacuating on each occasion 5-10 
c.c, or, in cases of considerably exaggerated pressure, up to 20 c.c. 

Attentive nursing is of the utmost importance in serous meningitis, 
in connection with which it is important to see that, in spite of dis- 
turbed consciousness, liquid food (milk) should be ingested and retained. 
By careful closure of the lids and laying moist compresses upon the 
eyes, acute keratitis due to lagophthalmos should be prevented. The 
skin should receive due care in order to prevent decubitus during the 
period of disturbed consciousness. 

After the serous meningitis has been cured, relapses need not be 
apprehended, children particularly recovering very rapidly without 
showing any impairment of their intellectual qualities. 

IV. CIRCUMSCRIBED SUPPURATIVE PACHYLEPTOMENINGITIS AND INTRA- 

MENINGEAL ABSCESS 

Anatomy. — Circumscribed otitic meningitis usually starts from 
inflammatory foci located on the medial surface of the dura. In the region 
of these foci the latter is thickened, grayish yellow, yellow, or yellowish 
green discolored, and dull. There are pus deposits in advanced cases, 
causing comparatively early infection of the leptomeninges and encepha- 
litis. The anatomical course varies. There may be agglutination of the 
pachy- and leptomeninges in the inflamed region, followed by regional 
adhesions, so that the spreading of pus and diffuse meningitis need not 
be apprehended. In other cases an intrameningeal abscess will develop, 
which may perforate and lead to a dural fistula and extradural abscess. 
In unfavorable cases the intrameningeal abscess will spread further, 



328 THE DISEASES OF CHILDREN 

leading to cerebral abscess or diffuse purulent meningitis, either by direct 
continuity of the inflammation or by way of metastasis. 

Another contingency is the formation of descending endocranial 
abscesses in cases where the pus accumulates at the lowest point of the 
medial or posterior cranial fossa. 

Etiology. — Circumscribed pachyleptomeningitis is usually caused 
by chronic middle-ear suppuration, complicated by an affection of the 
dura or a cerebral abscess. There is also danger of an intrameningeal 
abscess in many cases of long-persisting purulent sinus-phlebitis or of 
pachymeningitis externa. Circumscribed pachyleptomeningitis with 
cerebral abscess will occur at the place where the abscess is preparing 
to perforate. In this respect it is not an unfavorable complication, 
provided the intradural space is obliterated by inflammatory aggluti- 
nations in the region of the perforation, so that there is no apparent 
danger that the intact part of the intradural space will be invaded by 
the escaping pus. An intrameningeal otitic abscess will sometimes 
occur in the basal part of the posterior cranial fo.ssa in chronic suppura- 
tion of the labyrinth or sinus thrombosis. 

Circumscribed pachyleptomeningitis is very rare in acute middle- 
ear suppuration, and nearly always occurs by metastasis on the basis 
of acute, progressive extradural abscesses. It may also occur in the 
course of malignant tumors of the ear after exulceration, such tumor 
having either spread to the dura in the course of growth or having orig- 
inated in the dura. Furthermore, circumscribed meningitis is observed 
in fractures or fissures of the temporal bone if at the time of injury, or 
later, the middle ear has become infected, causing otitis media. 

Subarachnoid abscesses of the posterior cranial fossa are some- 
times caused by chronic suppuration of the labyrinth, with spreading 
of the pus to the internal auditory canal, and by suppurative otitis of 
the petrous bone (Fig. 112). These deep abscesses are an exceedingly 
dangerous complication of labyrinth suppuration. 

Symptoms. — Circumscribed pachyleptomeningitis is accompanied 
by stinging headache, referred to definite places, which, however, do not 
always correspond to the seat of inflammation. With extension of the 
affection to the parietal lobe, considerable accumulation of exudate may 
cause motor disturbances by impairment of the motor cortical region 
(spasms and, later, paralysis). In most cases there is sensitiveness to 
percussion of the temporal squama. Circumscribed pachyleptomenin- 
gitis of the posterior cranial fossa is accompanied from the onset by 
rigidity of the neck. Opisthotonos is usually present as soon as the 
meningitic changes extend to the base of the skull. The fundus of the 
eye shows unilateral or bilateral venous plethora. The cerebrospinal 
fluid is gray, turbid, and contains abundant mononuclear and poly- 



ENDOCRANIAL OTOGENIC AFFECTIONS 



329 



nuclear leucocytes; in most cases it is sterile. Aerobic or anaerobic 
micro-organisms of the most varied kinds are found in the meningitic 
foci. Proteus is found only exceptionally. 

Diagnosis. — It is only exceptionally that the clinical diagnosis of 
circumscribed meningitis can be made with absolute certainty, as in 
most cases the symptoms of the causative affection preponderate (sinus 

Fig. 112. 



Nviiivin 




M 



Cerebral base of a boy, fourteen years old. Subarachnoidal abscess (A) and circumscribed leptomenin- 
gitis (red) of the right cerebellar hemisphere in the area of the insertion of the auditory and facial nerves (N. 
VII, VIII). Natural size. P, pons; M, medulla oblongata. 

thrombosis, suppuration of the labyrinth, cerebral abscess, etc.). It is 
absolutely impossible to recognize the early stages of pachyleptomenin- 
gitis, as they may run a course entirely devoid of symptoms. At the 
time of operation a dural fistula, if present, would certainly disclose an 
intrameningeal abscess, but fistula formation is a comparatively rare 
occurrence. It follows that in an endocranial affection of the external 
dura (pachymeningitis externa, sinus thrombosis) we are, even with 
the advantages afforded by an operation, dependent upon other signs 
which render the presence of an intrameningeal abscess probable. These 
include considerable swelling of the dura, which is deeply loosened, in 



330 THE DISEASES OF CHILDREN 

other cases red or yellowish-green discoloration, fragility, inordinately 
strong tension or flexibility of the dura, deep fetid pus foci of the dura in 
sinus thrombosis, and also yellowish-green discoloration and fragility 
of the medial sinus wall, which can be inspected after opening the sinus 
and evacuating the thrombus. An intrameningeal abscess will betray 
itself in cases of labyrinth suppuration by the fact that after exposure 
of the dura, when resecting the labyrinth, pus will protrude from the 
region of the saccus endolymphaticus or from the apical region of the 
semicircular canal or from the internal auditory canal. 

An intradural abscess cannot escape attention in cases of abscess 
of the temporal lobe or cerebellum, since it is necessary anyway to open 
the intradural space in order to evacuate the cerebral abscess. By 
observing the fundamental rule in operating upon a cerebral abscess, 
to follow the tracts over which the ear affection has spread into the 
cranium, the intrameningeal pus focus is sure to be discovered. 

It is just in these cases of cerebral abscess, and in many cases of 
sinus thrombosis, that valuable assistance will be given by the findings 
of lumbar puncture. Turbid, sterile fluid is of immense importance for 
the diagnosis of circumscribed meningitis. 

Treatment. — Treatment can only be surgical. It consists in antrot- 
omy in acute middle-ear suppuration or radical operation in chronic 
cases, in exposure of the dura beyond the affected area, and in free 
incision of the dura. The method of effecting the latter is by incising 
layer by layer, because in this way it is possible to observe whether the 
pus emanates from the extradural or intradural space or from the brain 
itself. Direct puncture of the dura with the scalpel or, worse, with a 
hollow needle may infect the brain which may have been intact before, 
and, besides, will give no indication as to which spaces the evacuated 
matter originates from (extradural, intradural, or intracerebral). 

The wound is drained with iodoform or isoform wicks. The first 
change of bandage should take place two days after operation. 

Course and Result. — Many cases of circumscribed meningitis have 
a distinct tendency to remain circumscribed, a clinically important 
fact to which Voss first called attention. The prognosis is also favorable 
in cases where the intrameningeal abscess has existed for some time and 
is walled up by adhesions against the rest of the intradural spaces. 
The prognosis is less favorable in cases with symptoms of general menin- 
gitis and intradural abscess of the posterior fossa. In the latter cases 
the prognosis is unfavorably influenced by the fact that access to the 
abscess can be obtained only by an extensive and serious bone operation 
(exposure of the sinus or resection of the labyrinth) and that the una- 
voidable concussion of the endocranium caused by the chisel-work 
involves the danger of spreading the pus and advancing the meningitis. 



ENDOCRANIAL OTOGENIC AFFECTIONS 331 

Another point is that there is a tendency for the pus to descend to the 
fundus of the posterior cranial fossa. For this reason it is urgently 
necessary to renew the bandage and drains frequently, in order to pre- 
vent the retention of secretion. There should be no lumbar puncture 
while the wound is under treatment. 

V. ACUTE DIFFUSE SUPPURATIVE OTOGENIC PACHYLEPTOMENINGITIS 
(MENINGOENCEPHALITIS) 

Anatomy. — In diffuse suppurative otitic meningitis there is extensive 
intradural and subarachnoid accumulation of pus. In many cases of 
fully developed meningitis the otogenic origin is still distinctly recog- 
nizable by the fact that the inflammatory manifestations of the auricular 
region of the middle or posterior cranial fossa are in the most advanced 
stage, containing the oldest changes. In other cases the meningitic 
changes present no difference. 

These changes may spread to the spinal space in a short time. If 
the pus accumulation is extensive, intradural agglutinations may develop 
in the presence of thick, viscid pus, leading to hydrocephalus internus, 
possibly with occlusion of the foramen of Magendie, pus accumulation 
in the sinuses, at the fissura transversa, and copious accumulation of 
pus at the falx cerebri and the tentorium. 

Every case of diffuse pachyleptomeningitis is associated from the 
first with superficial encephalitis and superficial cerebral oedema. There 
will be swelling and softening of the brain, later inflammatory infiltra- 
tion, and, should the case be persistent, ulceration of the cerebral surface 
and abscess formation. Should meningitis have developed on the basis 
of a suppuration of the temporal bone extending to the endocranium, 
perforation may establish a primary or secondary communication be- 
tween the pus focus of the extradural space and the intradural inflam- 
matory focus. 

The anatomical changes in acute meningitis increase in extent and 
intensity rapidly and uniformly; at times, however, there is a transitory 
arrest of the process, from which the clinical type of intermittent men- 
ingitis develops. It should be admitted, however, that in the unques- 
tionably rare cases of intermittent meningitis there is usually the serous 
or tuberculous form at the bottom of the trouble, and but seldom the 
typical acute suppurative diffuse form. 

The bacterial findings reveal different micro-organisms according 
to the individual case. In the majority of them there is but one single 
species of micro-organisms (streptococcus, pneumococcus, pneumonia 
bacillus, staphylococcus, etc.), for the reason that but one bacillus has 
led to the inflammation or that the predominating one has outgrown 
the others. 



332 THE DISEASES OF CHILDREN 

Etiology. — Otitic diffuse suppurative meningitis occurs in the course 
of both acute and chronic middle-ear suppuration. In the first ten 
years of life otitic meningitis occurs far more frequently than any other 
otogenic affection. This is explained by the fact that a suppurative 
process occurring in the feeble structure of the infantile temporal bone 
rapidly penetrates to the dura, whence it readily spreads to the endo- 
cranium, owing to the intimate connection between the cerebral meninges 
and the surface of the bone. 

The impression is created that meningitis in these cases runs such 
a rapid course of development and termination that there is no time for 
other cranial affections to establish themselves, notably sinus-phlebitis 
or cerebral abscess. However, it is quite possible for diffuse suppurative 
meningitis to develop on the basis of any otitic endocranial affection. 

The danger of meningitis is particularly present in acute or chronic 
suppuration of the upper tympanic space and the antrum. Defective 
drainage with consequent retention of secretion in the middle ear causes 
the pus to be retained at the tegmen tympani in chronic cases; with a 
still passable fissura tympano-squamosa there will be purulent inflamma- 
tion of the dura filling out the fissure, leading to suppurative destruc- 
tion of the tegmen tympani with fistula formation, and the meningitis 
will then start from the pus focus in the bone. 

In acute otitis media, meningitis occurs most frequently in the 
metastatic form. There is no need for the bone to be diseased up to 
the dura; this is demonstrated at operation by the fact that there is no 
recognizable material topographic relation between the meningitic foci 
and the ear. 

Symptoms. — The ear symptoms usually correspond to those of a 
middle-ear suppuration with special participation of the upper space of 
the tympanic cavity and antrum or with retention in the attic and 
antrum. 

The first group also embraces cases where the communication be- 
tween meso- and epitympanum was reduced or obliterated before the 
suppurative otitis media was established by catarrhal affections, with 
the result that the pus originating from a later epitympanic inflamma- 
tion in the attic and antrum can only escape to the mesotympanum 
under difficulties, if at all. This is clinically evidenced by the fact 
that with all the signs of grave middle-ear infection (great pain, dif- 
ficulty of hearing, fever) even free paracentesis has no effect, or the 
pus secretion will soon be arrested again. After a short time the pos- 
terior upper wall of the auditory canal will descend, a diffuse flesh-like 
thickening of the tympanic membrane will develop, the hearing acuity 
will be considerably reduced, and in some cases there will be spontan- 
eous nystagmus and susceptibility to percussion of the temporal squama. 



ENDOCRANIAL OTOGENIC AFFECTIONS 333 

Typical mastoid symptoms are present in many cases, especially 
at the onset of the affection; but it should be particularly emphasized 
that, in spite of imminent or developed meningitis, such symptoms may 
be absent. Generally speaking, the cerebral symptoms and general 
manifestations predominate over the ear symptoms. 

Cerebral and General Symptoms. — The early symptoms include 
headache, restlessness, and sleeplessness. Sleep, if any, will last only a 
short time; the patient is restless and cries out repeatedly while asleep. 
The lid closure is imperfect and there is involuntary twitching in the 
region of the facial muscles. There is either absolute or relative slow or 
irregular pulse, with high fever and considerably increased frequency of 
respiration, hyperesthesia of the skin, paresthesia of the extremities, 
and exaggeration of the tendon reflexes. Kernig's symptom (flexural 
contraction of the knee-joint on flexure of the leg) is positive. Free 
motility of the head is soon impaired, followed or not followed by rigidity 
of the neck. Later there will be attacks of delirium lasting a considerable 
time, convulsions, and typical cerebral vomiting (by the "mouthful," 
without any particular exertion or any subsequent feeling of relief). 
The pupils are narrow or unequal at an early stage and there is dimin- 
ished or irregular reaction of the pupils to light. At a later stage there 
are often exophthalmos and spontaneous coarse nystagmus, which may 
be' straight or horizontal. In advanced cases there are abducent paraly- 
sis of vision, disturbances of speech and respiration, and loss of conscious- 
ness. The veins of the ocular fundus are very plethoric, or there is 
choked disk (which, however, in rapidly fatal cases has no time to de- 
velop) ; finally, there is paralysis of the special senses of smell and taste 
and of the tongue muscles. 

As the process advances there will be paralysis of the intestine and 
bladder, involuntary defecation and micturition, or retention of urine. 
There is a striking pallor of the skin both on the face and over the body. 
The cheeks are often tinged a deep red, which sharply contrasts against 
the pallor or subicteric discoloration of the surrounding skin. 

Diagnosis. — The diagnosis of otitic meningitis, when fully devel- 
oped, presents no difficulties on taking the above symptoms into con- 
sideration. Recognition of the early stages of the affection presupposes 
considerable clinical experience. Any case of otitis media with contin- 
uous fever, severe diffuse headache, restlessness, dyspnoea, and sleepless- 
ness must arouse suspicion if the local inflammation does not run a 
satisfactory course. Hyperesthesia of the skin, dermographia, exagger- 
ated tendon reflex, and positive Kernig point to meningitis. Observa- 
tion of the patient during the night is of great importance. Crying out 
or frequently starting up while asleep, involuntary twitching of the 
mimic musculature, and lagophthalmos must arouse the suspicion of 



334 THE DISEASES OF CHILDREN 

meningitis. In order to make a correct diagnosis, lumbar puncture is 
necessary in all such cases; in the early stages, or when the affection runs 
an insidious course, it will guard against diagnostic errors. 

Differential Diagnosis. — Differentiation between serous and diffuse 
suppurative meningitis is often an easy matter. Rapid development of the 
pathological picture and rapid involution of the manifestations point to the 
serous form. Rigidity of the neck, spontaneous nystagmus, persistent high 
fever, slow but steady increase in the intensity of the pathological mani- 
festations, and paralysis of the intestine and bladder point to the suppu- 
rative form. However, there are many cases in which an exact differentia- 
tion between these two forms is only possible by lumbar puncture. 
Should the communication between the intradural spaces and the ventri- 
cles be obliterated, lumbar puncture may be negative, as this condition 
makes it impossible for the cerebrospinal fluid to be evacuated. 

The differential diagnosis between acute purulent and tuberculous 
meningitis will not cause any difficulties. Tuberculous meningitis often 
develops with normal or slightly elevated temperature; a higher acces- 
sion of temperature does not usually occur except shortly before death. 
Besides, in tuberculous meningitis there are practically no irritative 
symptoms, such as delirium, convulsions, and unrest. In doubtful cases 
lumbar puncture cannot be dispensed with. 

Treatment. — Diffuse suppurative acute meningitis can only be 
treated by surgery, commencing with the ear operation. In acute 
middle-ear suppuration the cerebral operation has to be preceded by 
antrotomy, in chronic cases by the radical operation. Instead of a 
chisel, Luer's forceps should always be used wherever possible. The 
saw is not to be recommended, as the bone dust interferes with the con- 
trol of the work. The ear operation is followed by exposure of both 
cranial fossa?. The middle cranial fossa is opened by an incision in the 
shape of a cross, after which drainage wicks are inserted between the 
protruding brain and the inner surface of the dura. Should the dura 
present any pathological changes, the dura of the posterior cranial 
fossa need not yet be resected. In the absence of any particular inflam- 
matory manifestations, it is advisable to resect at once the posterior 
cranial fossa both in front and behind the sinus sigmoideus. In the 
event of there being still another endocranial affection, the operation 
should include this as well. 

Lumbar puncture is best carried out following the ear operation. The 
quantity to be withdrawn depends upon the pressure under which the cere- 
brospinal fluid is evacuated, but more than 10-15 c.c. should never be 
withdrawn at one sitting. If lumbar puncture were carried out preceding 
the ear operation, or if the quantity withdrawn be too large, there would 
be danger of intradural hemorrhages during the ear operation. 



ENDOCRANIAL OTOGENIC AFFECTIONS 335 

The first change of bandage is made two days after the operation, 
special care being taken to maintain intradural drainage. Unfortunately, 
this is not always an easy matter in pronounced cerebral oedema and 
superficial softening of the cerebral substance. In small openings of 
the dura there is danger of retention; in large openings there may be an 
extensive prolapse. In some cases aspiration is successful, as recom- 
mended by Manasse. From a therapeutic stand-point repetition of 
lumbar puncture once or twice a week may be beneficial. 

Course. — In spite of the great strides made in otological surgery, 
the operative success in diffuse suppurative meningitis is very slight. 
There is some chance for the following forms : 

(1) Staphylococcus meningitis, several successful cases having been 
reported in the literature. It is not impossible, however, that some of 
these cases were serous meningitis, and that the staphylococcus found 
at the bacteriological examination was an accidental impurity. 

(2) Labyrinthogenic meningitis. This group includes cases of 
streptococcus and pneumococcus meningitis. It is perfectly true that 
labyrinthogenic meningitis properly belongs to circumscribed menin- 
gitis, and that the posterior cranial fossa is completely or exclusively 
attacked on the side of the affected labyrinth and close to the latter. 
This explains why a timely resection of the labyrinth in these cases, 
followed by opening of the posterior cranial fossa, will lead to a cure. 

All the other forms of diffuse suppurative acute meningitis are 
prognostically very unfavorable. Whatever hope is entertained to 
effect a cure by timely and extensive operation and drainage is in a 
large number of cases doomed to disappointment. The thick, viscid pus 
accumulates in the deep subarachnoid fissures and cisterns to such an 
extent that there can practically be no question of effective draining or 
removal of the matter in fully developed cases. 

VI. OTOGENIC TUBERCULOUS MENINGITIS 

Anatomy and Etiology. — Tuberculous otogenic meningitis always 
occurs in the wake of a chronic, usually bilateral, suppuration of the 
middle ear. In most cases this suppuration is tuberculous, but the fact 
has been established that tuberculous meningitis may be caused by non- 
tuberculous suppuration of the middle ear in a patient suffering from a 
chronic tuberculous affection at some other part of the body, such as 
the bones, lungs, or abdomen. 

The danger of contracting otogenic tuberculous meningitis is par- 
ticularly great in neglected tuberculous suppuration of the middle ear, 
as well as in cases where the tuberculous ear affection is complicated by 
a tuberculous affection at some other part of the body, such as the lym- 
phatic glands, lungs, intestinal tract, bones, and joints. Tuberculous 



336 THE DISEASES OF CHILDREN 

meningitis may also be postoperative in chronic tuberculous suppura- 
tion of the middle ear if the radical operation has become necessary. 
Furthermore, the danger of tuberculous meningitis exists in chronic 
tuberculous suppuration of the labyrinth and in tuberculous caries of 
the petrous bone. 

The anatomical findings are characterized by the presence of miliary 
nodules of the leptomeninx along the blood-vessels of the brain. Exten- 
sive superficial pus foci are comparatively rare. Single or multiple 
cerebral tubercles will develop in many cases. The inflammatory 
exudate, which is of a serofibrinous or gelatinous consistency, is chiefly 
located at the base of the skull in the region of the large sinus, leading 
in a short time to hydrocephalus internus and ependymitis granulosa. - 

In exceptional cases a special topographical relation between the 
localization of the nodules and the affected ear can be recognized; usu- 
ally, however, the meninges of both sides are affected in cases where 
only one ear is diseased and without any recognizable causal relation. 

Symptoms. — As compared with acute suppurative meningitis, the 
tuberculous form is characterized by its insidious development and but 
slight intensity of whatever symptoms may occur. It remains in a 
latent condition for a long time. The prodromal manifestations consist 
in a gradual increase of feebleness, no desire to eat or take exercise; 
children have no desire to play or study. Early symptoms are vomiting 
and insomnia or disturbed sleep. There may also be indigestion. The 
temperature is either normal or slightly elevated. There are involuntary 
movements of sucking or mastication, the reflexes are exaggerated, 
and the muscle tonus is generally increased. The pulse is slow, the 
pupils are narrow or uneven, reaction to light may be maintained, 
incomplete, or entirely absent. 

There is at first light coma, which, in the further course of the 
disease, increases to deep unconsciousness. The patient is unable to 
swallow; there is motor irritation in the shape of involuntary muscular 
twitching of the face, trunk, and extremities, which terminates in paraly- 
sis, increasing debility, and death. 

Diagnosis. — The diagnosis of tuberculous otogenic meningitis 
requires considerable experience, especially in the early stages, as the 
symptom-complex is often incompletely developed or entirely absent 
in the latent period. Middle-ear suppuration setting in and progressing 
without any symptoms points to its tuberculous character. Another 
characteristic point is the presence of a particularly small perforation, 
with copious and very fetid suppuration which has persisted for a num- 
ber of years. A tuberculous family taint will often arouse our first 
suspicion of tuberculous meningitis. The exact diagnosis can be made by 
lumbar puncture, the exudate showing a network of minute coagula- 



ENDOCRANIAL OTOGENIC AFFECTIONS 337 

tions (Fig. 117). Careful examination will also demonstrate the tubercle 
bacillus in 75 per cent, of the cases. 

Treatment. — An ear operation offers no chance of success. Tem- 
porary improvement is sometimes achieved by lumbar puncture, daily 
repetition of which has been recommended. Withdrawal of blood from 
the mastoid by the application of leeches, inunction with green soap, 
and creosote internally, have also been recommended. 

Course. — Tuberculous meningitis lasts from one or two weeks to 
several months. 

In cases which run a protracted course, temporary improvement 
is not a rare occurrence. The fully developed symptoms may be pre- 
ceded by a long state of irritation resembling serous meningitis. The 
latter is apparently cured, but, after a subjective feeling of well-being 
for several weeks or months, the signs of tuberculous meningitis set in. 
Aside from exceptional cases of improvement which have been reported, 
the course of the disease is always fatal. 

VII. OTOGENIC ABSCESS OF THE TEMPOROSPHENOID LOBE 

Anatomy. — The abscess is usually located in the basal part of the 
temporosphenoid lobe, more or less turned toward the tegmen tympani. 
Toward the outside it extends to the cortex of the temporal lobe, reach- 
ing the medial and sometimes the upper temporal convolution (Fig. 113). 
Medially the abscess extends in the direction of the descending horn of 
the lateral ventricle and the crus cerebri; anteriorly it extends to the 
operculum (Plate IX) ; posteriorly it varies considerably in extent. In 
most cases the abscess does not project beyond the tympanosphenoidal 
lobe, and it is only in exceptional cases that it continues to the anterior 
portion of the occipital lobe. 

The size of these abscesses is from a hemp-seed, in suppurative 
superficial encephalitis, to a man's fist. They are spherical or oval, 
rarely irregular or ramified. Transition forms of multiple abscesses, 
which intercommunicate by small canals, are rare. 

The pus in a cerebral abscess is under considerable pressure, and 
usually completely fills the abscess cavity. It is mostly putrid and rarely 
of liquid consistency. 

There are always necrotic cerebral and fibrinous substances mixed 
with it, all of which are evacuated together. The exuding pus is in most 
cases fetid, non-fetid pus being only occasionally found in acute and 
such chronic cases as have been opened in the latent stage. In the 
manifest stage which very often occurs by acute endocranial reinfection 
the pus is generally ichorous. 

The pyogenic factors vary considerably in different cases. Usually 
there is but one species of micro-organism present in any one case, 

VI— 22 



338 



THE DISEASES OF CHILDREN 



together with anaerobic bacilli. Cerebral abscesses with mixed infec- 
tions, or containing the colon or proteus bacillus, occur less often. A 
study of a large number of cases, however, will show that nearly all 
kinds of pyogenic factors may occur in abscesses of the temporal lobe. 
In chronic cerebral abscesses the culture may remain sterile, which is 
undoubtedly due to the destruction of the micro-organisms previous to 
evacuation, so that they can no longer be demonstrated. 

Abscesses of the temporal lobe are usually enclosed in a fibrinous 
capsule which fairly well protects the neighboring cerebral substances 
from infection. The capsule is smooth toward the contents of the ab- 
scess, there being no protrusions. In cases which have persisted for 



Fig. 113. 




Abscess of temporo-sphenoidal lobe; chronic suppurative pachyleptomeningitis after intradural perforation of 

abscess (a). 

some time the capsule contains an abundance of pigment. The inde- 
pendence of the capsule is in many cases demonstrated at operation or 
during the healing process. It is usually spontaneously expelled a few 
days after the abscess has been emptied. 

The cerebral substance in the vicinity of the abscess is in all cases 
more or less compressed. There may be displacement and change of 
form of the lateral ventricle, even compression of the crus cerebri in the 
region of the lemniscus or at the emergence of the trochlear nerve. 
The cerebral substance in the vicinity of the abscess contains small 
round-cell infiltration, and there are various stages of cell necrosis and 
thrombosis of the smallest cerebral vessels. Characteristic cross sec- 
tions of an otogenic abscess of the left temporal lobe are illustrated on 



ENDOCRANIAL OTOGENIC AFFECTIONS 339 

Plate IX. The size of the abscesses is in some cases more dependent on 
displacement of the neighboring tissue than on suppurative degenera- 
tion of the cerebral substance. This fact is demonstrated by anatomical 
examinations of the bone in cases of abscess of the temporal lobe, show- 
ing, as they do, that in the region of the abscess but a small part of the 
fibres has been completely destroyed, the larger portion being displaced 
or compressed in the neighborhood of the abscess. This anatomical 
fact is also confirmed by clinical experience, operative removal of an 
extensive abscess of the temporal lobe being always followed by such a 
rapid reduction of the abscess cavity that in from one to two weeks 
after operation a cavity the size of a small apple may have been reduced 
to that of a prune. This reduction can, of course, not be the consequence 
of tissue regeneration in so short a time, and, besides, local examination 
will show that it is but to a small extent produced by blood coagula or 
fibrinous masses. The fact is that by evacuation of the abscess the 
pressure on the brain has been removed and the displaced parts are 
returning to their normal location. 

After the abscess has persisted for several weeks there will be 
softening and oedema of the cerebral substance in the more or less dis- 
tant vicinity of the abscess, which is evidently occasioned by congestion. 
The brain assumes a pathologic reddish tint ; the cerebral cortex becomes 
softened and is easily compressible. 

The soft parts between the temporal bone and the basal surface 
of the abscess show various changes according to the origin of the abscess. 
Direct spreading of the suppuration from the epitympanum to the brain 
is only rarely responsible for the formation of the abscess. Where it 
does occur, the process is preceded by pachymeningitis externa and 
interna and by superficial suppurative encephalitis. All these cases of 
cerebral abscess are complicated by an intradural abscess, and most of 
them by an extradural abscess. The lymph-spaces between the pachy- 
meninges and the cerebral surface are replete with pus, or in older cases 
are obliterated by connective tissue, owing to the secretion of fibrinous 
masses. A fistulous canal, filled with pus, leads from the auricular 
region into the cerebral cavity. 

In cerebral abscesses of metastatic origin the soft layer between 
the base of the abscess and the bones (labyrinth, tegmen) is at first 
unchanged except for the cedematous swelling of the brain. Later there 
will be congestive manifestations of the dura; the dural vessels are full 
to turgescence, finally leading to softening, swelling, and inflammation 
of the dura. A fibrinous communication between the inner surface of 
the dura and the arachnoidea will establish itself, causing the formation 
of a thick, callous layer between the temporal bone and the lower sur- 
face of the abscess, in the event of the latter running a chronic course. 



340 THE DISEASES OF CHILDREN 

Anatomical Course and Result. — There is a theoretical possibility 
for a spontaneous cure of cerebral abscess taking place by calcareous 
degeneration of the purulent contents and obliteration by connective 
tissue, but I have never been able to observe such a case. Once the 
abscess has grown to the topographical limit and its inside pressure is 
sufficiently high, the usual result is perforation into the neighboring parts. 
Such perforation may even occur in relatively small abscesses when 
located near the cerebral surface of the lateral ventricle. The perfora- 
tion occurs outward into the intradural or subdural space or inward 
into the lateral ventricle. The former event will cause diffuse infectious 
suppurative meningitis, as long as the normal communication of all 
subdural spaces still exists, or, should the region of the perforation be 
closed against the other subdural spaces by fibrinous or connective- 
tissue adhesions, an intradural abscess will develop. In the presence 
of a fistula, however, leading outward or into the middle ear, the cerebral 
abscess may evacuate outward and lead to a cure. This favorable 
result may sometimes be observed clinically on the occasion of a radical 
operation in the stage of latency and simultaneous exposure of the dura. 
Thus, I observed spontaneous evacuation of a cerebral abscess from a 
rupture which occurred when changing bandages, without giving rise 
any symptoms. 

Perforation of an abscess of the temporal lobe into the lateral ventricle 
always causes the development of infectious suppurative meningitis. 

The behavior of the cerebral meninx and of the cerebrospinal fluid 
in the presence of an abscess of the temporal lobe deserves special con- 
sideration. It has already been stated that there will be early oedema of 
the brain and inflammatory softening as well as thickening of both the 
dura and pia, especially in the region of the abscess base. These menin- 
gitic changes, which occur as concomitant symptoms of the abscess 
formation, are accompanied by typical changes in the cerebrospinal 
fluid. Lumbar puncture in cerebral abscess yields a fluid under patho- 
logically increased pressure, even if the abscess is not very large and 
closed in on all sides. The fluid is turbid and discolored gray or grayish 
yellow. After six to twenty-four hours it will form minute fibrinous 
coagulations in the undisturbed test-glass, and the microscopic exami- 
nation of the sediment— obtained with or without the centrifuge — shows 
an abundance of mono- and polynuclear leucocytes. Micro-organisms, 
however, are not present, either microscopically or by culture, unless 
there is a perforated cerebral abscess. The lumbar fluid, therefore, is 
sterile. This suppurative, non-infectious form of meningitis, which may 
also be present in other intracranial otogenic affections, is a typical and 
very valuable symptom for the differential diagnosis of most otogenic 
abscesses of the temporal lobe. 



ENDOCRANIAL OTOGENIC AFFECTIONS 341 

The reduction of the abscess cavity after evacuation of its contents 
is occasioned by the extension of the neighboring cerebral parts which 
had been compressed by the abscess, and by granulations which gradually 
become organized. The remaining gap will be gradually closed by con- 
nective tissue which starts growing from the dura, but the number of 
cases where the former abscess cavity has been completely obliterated 
is very small. In most cases small cysts will persist in the region of 
the incision or perforation, which are filled with a clear liquid contain- 
ing normal or degenerated round cells. It may be possible that an acute 
middle-ear suppuration will infect these cysts, causing fresh abscess 
formation or suppurative meningitis. This is a contingency that should 
be duly considered in treating the wound and making the prognosis. 

Symptoms. — The symptoms to be expected on the part of the 
affected auditory canal are but few and in no case very characteristic 
or prominent. Nor are there any particular changes to call the patient's 
attention to the gravity of the complication, unless by way of exception. 
The origin of an otitic abscess of the temporal lobe is a suppurative infec- 
tion of the upper space of the tympanic cavity in most cases, thus rep- 
resenting the epitympanic type of a middle-ear suppuration which is 
nearly always chronic. Inflammatory mastoid manifestations do not 
belong to the typical picture of a suppuration of the middle ear compli- 
cated by an abscess of the temporal lobe. 

Against these typical cases there are a small number of others in 
which the abscess of the temporal lobe occurs as the result of a chronic 
middle-ear suppuration with copious fetid secretion, involving all the 
middle-ear spaces. 

The pathological process as such commences almost without excep- 
tion in an insidious way under vague general manifestations (feebleness, 
lassitude, anorexia, diffuse headache, sometimes nausea and vomiting). 
The picture may at first be complicated by ear symptoms. If the latter 
have led to suppurative degeneration of the tegmen tympani, even 
transitory retention of pus will cause headache, a sensation of heaviness 
in the head and of fulness in the ear, which may be accompanied by 
violent subjective noises. In such cases, therefore, where the abscess 
has developed through direct spreading of the ear suppuration, these 
symptoms are the precursors of the abscess symptoms, from which it is 
sometimes impossible to differentiate them. In an abscess of the tem- 
poral lobe which has developed by metastasis there may be no auricular 
symptoms whatever. 

There is nothing pathologically characteristic in the body tempera- 
ture, which is either moderately raised or subfebrile, in rare cases normal, 
or in the latent stage sometimes subnormal. In a few cases there is 
fever of a pronounced intermittent character. Perforation of the ab- 



342 THE DISEASES OF CHILDREN 

scess is nearly always associated with a considerable rise in temperature, 
up to 104° or more, sometimes complicated by chills. 

In the further course of the disease there will be symptoms to be 
attributed to increased cerebral pressure or to cerebral changes in the 
direct vicinity of the abscess (cerebral oedema, encephalitis). They 
consist in headache, irregular and retarded pulse in the initial stage, 
cranial susceptibility to percussion, congestive manifestations of the 
ocular fundus, nausea, vomiting, narcolepsy, disturbed consciousness, 
delirium, tonic and clonic spasms. 

In the acute stage of the abscess there are pathological symptoms 
which are caused by the destruction of cerebral substance and by inter- 
ruption of the nerve conduction (focal symptoms). These include 
spastic and paralytic manifestations of the facial muscles of the same 
side and of the extremities on the opposite side. Simultaneous mani- 
festations on the part of the facial muscles and extremities occur in 
pathological foci located in the internal capsule. In right-handed 
individuals abscesses of the left temporal lobe may lead to lingual dis- 
turbances (amnestic aphasia, paraphasia, conduction aphasia, and in 
rare cases to optic aphasia and word-deafness). Amnestic and motor 
agraphia is not an unusual occurrence. There may also be paralysis of 
the oculomotorius, as evidenced by ptosis, mydriasis, and divergent 
strabismus. Pressure of the cerebral abscess upon the crus cerebri 
causes early disturbances in the region of the trochlear nerve on the 
affected side. Simultaneous paralysis -of that nerve may be regarded 
as a direct characteristic sign for an otogenic abscess of the temporal 
lobe. There may also be irritative and paralytic manifestations on the 
part of other cerebral nerves, notably disturbances of smell (anosmia). 
On the other hand, symptoms of those cerebral nerves which leave the 
skull through the posterior cranial fossa are usually absent. Symptoms 
in the region of those nerves and rigidity of the neck will not occur 
unless diffuse suppurative infectious meningitis has developed from 
perforation into the ventricles or subdural spaces. In unilateral auricular 
affections the hearing acuity of the other, normal, ear may be impaired, 
owing to a lesion of the crossed hearing centre in the affected temporal 
lobe. 

The complete course of symptoms corresponds to a division into 
four clinical stages: (1) initial stage, (2) latent stage, (3) manifest 
stage, (4) terminal stage. 

The initial stage is characterized by general symptoms such as 
anorexia, lassitude, fatigue, dislike to work, and sometimes vomiting 
after ingestion of food. The picture may also be complicated by auric- 
ular symptoms. Furthermore, there are usually diffuse headache in the 
neighborhood of the affected ear, vertigo, disturbed consciousness at 



ENDOCRANIAL OTOGENIC AFFECTIONS 343 

night lasting for a few minutes, short slight spasms of the extremities 
of the opposite side, transitory fever and delirium. The pathological 
symptoms in the initial stage, lasting for two or three weeks, will gradually 
disappear. 

In the latent stage, which lasts from three to twelve weeks, the 
patient may feel tolerably well, but usually disturbed sleep and a feeling 
of infirmity will persist. The patient looks depressed and is easily fatigued 
after short, slight muscular exertion. 

The latent stage nearly always passes into the acute stage without 
any warning. For instance, after a more than usually restless night a 
grave pathological picture may suddenly be present, consisting in vom- 
iting, delirium, spasms of the extremities, and twitching of the facial 
muscles. There are lingual disturbance, paralytic and other disturbances 
of vision, and increase of the spasms, vomiting, and delirium. This stage 
is usually accompanied by tormenting, localized headache, considerable 
susceptibility of the skull to percussion, fever, delirium, exaggerated re- 
flexes, general hyperesthesia, and ankle clonus. The acute stage, which 
lasts from one to fourteen days, may pass into the terminal stage under 
almost imperceptible exacerbations or quite suddenly. 

The symptoms of the cerebral abscess are now less pronounced 
than those of otitis. Coma takes the place of delirium, spastic par- 
oxysms no longer occur, but there is paralysis of the extremities of the 
affected side, paralysis of the oculomotorius, exophthalmos, frequent 
cerebral vomiting, diarrhoea, and incontinence of fasces and urine. Death 
occurs in deep coma after paralysis of all motor and sensory functions 
has further increased. 

Diagnosis. — The diagnosis of abscess of the temporosphenoidal lobe 
is difficult in the first stage, but a careful examination of the ear will 
always have to be made if a perfectly satisfactory explanation of the 
general and local complaints cannot be detected by an internal exami- 
nation of the body. An experienced observer will then be able in many 
cases to diagnosticate an intracranial complication. An exact differ- 
entiation from circumscribed meningitis and an extradural abscess, 
however, will not be possible in this stage, nor in any subsequent stage. 
From a practical point of view, however, such a differential diagnosis 
is immaterial. The important diagnostic point is to establish intra- 
cranial complication in the area of the middle cranial fossa, from which 
the necessity of immediate surgical intervention would clearly follow. 
The experienced otological surgeon will then be able to make an exact 
diagnosis at the operation, from the dural changes and the exposed brain, 
and, according to the findings, proceed to the opening of the abscess. 

There can be no question of a clinical diagnosis of abscess of the 
temporal lobe during the latent stage. Experience, however, shows 



344 THE DISEASES OF CHILDREN 

that it is just during this stage that many abscesses can be successfully 
operated upon. The discovery of the abscess is nearly always accidental 
on the occasion of a radical operation which may become necessary 
from some other pathological symptom. 

The following case may serve as an example : 

In a case of chronic suppuration of the attic, conservative treat- 
ment is persisted in for a long time; the fetid character of the suppura- 
tion is not improved and there is headache. Radical operation is now 
decided upon, and the roof of the tympanic cavity is found softened 
from suppuration, while the middle-ear spaces contain but very little 
pus. These findings would not explain the grave complaints. Upon 
resection of the middle cranial fossa, a considerable vascular injection 
suggests the proximity of the abscess, which is now uncovered and evac- 
uated by incision. 

I have also operated upon two cases where after the radical opera- 
tion the abscess spontaneously evacuated through a pathological fistula 
during the process of healing. In one of the cases the radical operation 
was carried out upon the relative indication of persistent fetid suppura- 
tion of the middle ear, the bone being likewise demonstrably involved. 
Hearing acuity of the other ear was normal. The operation disclosed 
osseous changes of the roof of the tympanic cavity, which was therefore 
removed. The healing process took a perfectly normal course; the 
patient felt perfectly well; but during a change of bandage there was 
spontaneous perforation and evacuation of the cerebral abscess outward. 
The other case was similar. After operation the patient stated that he 
suddenly felt large quantities of fluid flowing into his ear. Immediate 
change of bandage showed that a latent abscess of the temporal lobe 
had been evacuated into the bandage. In both cases the abscesses were 
large, containing about 80 c.c. of pus. 

The diagnosis in the acute stage usually presents no difficulties. 
The choked disk and the paralysis of the trochlearis, which can be recog- 
nized by careful examination, are valuable symptoms. To these are 
added the characteristic lingual disturbances in right-handed people 
with abscess on the left side. Besides, the other symptoms mentioned 
above are not present in such characteristic relationship in any other 
endocranial affection as in abscess of the temporal lobe. 

The clinical diagnosis of cerebral abscess is often impossible in the 
terminal stage, since all that can be recognized is the purulent menin- 
gitis it has caused. The only way to discover these abscesses is to resort 
to operation in purulent otitic meningitis. The idea of regarding puru- 
lent meningitis as inoperable may at the present time be looked upon 
as absolutely exploded: it was owing to this very idea that many a case 
of abscess of the temporal lobe remained unoperated upon in the ter- 



ENDOCRANIAL OTOGENIC AFFECTIONS 345 

minal stage, because of the erroneous diagnosis of suppurative diffuse 
meningitis. Thus, the presence of a cerebral abscess, opening of which 
might have saved the patient's life, was only discovered at autopsy. 

Differential Diagnosis. — In the initial stage all the conditions 
should be considered which are accompanied by general, though not 
pronounced, symptoms, such as dejection, fever, headache, fatigue on 
slight -exertion. Very often a diagnosis is made of "cold," indigestion, 
hysteria (!), anaemia, etc., and it is in this stage that mistaken diagnoses 
are of such frequent occurrence that the number of correct ones are 
decidedly in the minority. An early diagnosis of an intracranial affec- 
tion is often possible by examining the ocular fundus, which should be 
done in all cases. 

A differential diagnosis between abscess of the temporal lobe and 
any other otitic affection of the medial cranial fossa before operation 
is often impossible in the terminal stage, although lumbar puncture 
may be of assistance. This requires not only microscopic examination, 
but also observations as to coagulation and culture experiments. This, 
however, cannot be accomplished in less than one to two days, and, as 
the operation is exceedingly urgent, it does not seem advisable to defer 
it for that length of time. 

Treatment. — The treatment of otogenic abscess of the temporal 
lobe is surgical. It consists in opening the middle cranial fossa, exposure 
and opening of the regional dura, and evacuation of the abscess. As a 
preliminary act, antrotomy is done in cases of acute suppuration of the 
middle ear, and the radical operation in chronic cases. 

If the general condition of the patient is unfavorable, these oper- 
ations must be carried out as rapidly as possible. I am in the habit in 
such cases of deferring the plastic of the auditory canal until a later 
time, in order to get as rapidly as possible to the middle cranial fossa. 

Exposure of the dura may be effected in the following ways : 

(1) Starting from the squama of the temporal bone. 

(2) Removal of the roof of the tympanic cavity. 

(3) Removal of the tympanic roof, the upper wall of the auditory 
canal, and the neighboring part of the squama. 

The first method is the oldest. In this now discarded way the 
abscess can only be discovered in very few cases, because the bone is 
exposed at a point far away from the otogenic origin of the abscess. 
In former times it was even customary to confine the operation to this 
insufficient measure, omitting the operation on the ear entirely. The 
consequence is that the cause of the abscess will persist. Even should 
it be possible to evacuate the latter, the suppuration of the ear will 
continue, leading to postoperative, rapidly fatal meningitis; otherwise, 
the patients will succumb to a recurrence of the cerebral abscess. 



346 THE DISEASES OF CHILDREN 

The second method, which consists in gaining access to the middle 
cranial fossa by removing the tegmen tympani, unquestionably offers 
the best possibility of finding the abscess and of establishing sufficient 
drainage of the abscess cavity, as it follows the track over which the 
infection has occurred. The method, however, has many disadvantages. 
The deep horizontal aperture does not admit of freely surveying the 
cerebral changes themselves. In metastatic formation of the abscess it 
will be necessary to explore the brain with the scalpel in various direc- 
tions. The opening of the tegmen, however, considerably interferes with 
exploration toward the posterior part of the temporal lobe and the occip- 
ital lobe ; in fact, exploration in certain directions is quite impossible. It 
is not surprising, therefore, that in metastatic abscesses of the temporal 
lobe removal of the tympanic roof will not attain the desired end. 

Under these circumstances clinical requirements have led to the 
development of the third operative method, which we now employ in 
every case. We commence with the exposure of the middle cranial 
fossa by removing the roof of the tympanic cavity, the upper wall of 
the auditory canal, and the neighboring part of the squama. From the 
aperture thus obtained the bone is resected laterally to the zygomatic 
process and to the base of the squama. This admits of a full survey of 
the region and of inspecting the affected cerebral cortex. 

By carefully lifting the dura it can be ascertained whether there 
is an extradural abscess or not. If so, the dura is opened at the most 
affected place, either by a longitudinal incision of 1-2 cm. or by a cross- 
wise incision. Larger dural vessels should be avoided, in order to pre- 
vent the occurrence of disturbing hemorrhages. The tension of the 
dura varies. If the abscess has not yet perforated, the dura is hard, 
elastic, and very tense. The tension is increased considerably beyond 
normal. If perforation has taken place, there may be distinct fluctu- 
ation with high pressure; if it has occurred into the subdural spaces, the 
dura may be quite relaxed, with much fluctuation, and may even be 
synchronous with the pulse. 

Incision. — The dura is incised layer by layer, until the bone is 
exposed; the latter is then also incised. By following this rule it will 
be possible to distinguish from which region the pus emanates and 
whether the abscess had or had not subdurally perforated. The pus, 
intermingled with brain particles, rapidly rushes out, or even spurts 
out if the tension is very high. A little later it exudes with the pulse 
movements. Evacuation of the abscess is usually followed by lumpy, 
fibrinous masses. The cavity should neither be washed nor dried; it is 
simply drained by means of iodoform or isoform wicks. 

The first change of bandage is made two to three days after the 
operation. The drains are shortened on this and every subsequent 



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ENDOCRANIAL OTOGENIC AFFECTIONS 347 

occasion, so that the drains will not be entirely removed until eight to 
ten days after operation. Further treatment should take the rapid 
healing of the dural aperture above the tympanic roof into considera- 
tion. With this end in view, the abscess cavity is drained through the 
upper outer end of the aperture in the area of the temporal squama. 
It will then be possible to undertake the undisturbed treatment of the 
trauma caused by antrotomy or the radical operation, quite indepen- 
dently of the cerebral opening. 

Treatment of the abscess cavity from the tympanic cavity would, 
of course, cause the dural aperture above the tympanic cavity to persist 
for a long time, with the consequence of an atropic scar of the dura. 
Besides, the dural trauma is always covered over by cicatricial tissue 
which develops during the healing process of the middle ear and which, 
in the presence of an atropic dura, may lead to headache requiring a 
plastic operation for removal. On the other hand, the dura has already 
healed with scar-formation in the area of the tympanic roof and antrum 
if the abscess cavity is treated from without. 

Patients generally make a rapid recovery, their appearance is 
excellent, and they rapidly increase in weight; but for a long time after- 
ward they are entirely unfit for any intellectual or physical work. 

The prognosis is not unfavorable; it chiefly depends upon the age 
of the patient and upon whether the abscess has already undergone 
perforation or is still entirely closed. In older individuals the prognosis 
is less favorable than in young ones. Cases in which the abscess is still 
entirely closed give better chances for an operation than where perfora- 
tion has taken place. Perforation of the abscess toward the ventricle 
renders the prognosis absolutely unfavorable. With perforation into the 
subdural spaces, healing may still take place, even in the presence of 
suppurative meningitis. 

VIII. OTOGENIC CEREBELLAR ABSCESSES 

Anatomy, Etiology, and Occurrence. — Otitic cerebellar abscesses 
are rarely observed in the course of acute middle-ear inflammation. It 
always occurs in complicated acute middle-ear suppuration which has 
already led to suppurative mastoiditis, extradural abscess, intradural 
abscess, or pyaemic sinus thrombosis. Exceptionally a tuberculous cere- 
bellar abscess may develop through ulceration or cerebellar tubercles in 
cases of subacute tuberculous middle-ear suppuration. 

In chronic middle-ear suppuration a cerebellar abscess develops in 
most cases on the basis of chronic or acute diffuse suppuration of the 
labyrinth. 

Fig. 114 illustrates the infectious tracts which may play a part in 
the spreading of middle-ear suppuration to the posterior cranial fossa. 



348 



THE DISEASES OF CHILDREN 



It will be seen that 5 of the 7 tracts — namely, Nos. 2, 3, 4, 6, and 7 — 
pass through the labyrinth, and in these cases the cerebellar infection is 
preceded by suppurative inflammation of the labyrinth, whether the 
abscess has developed by spreading of the suppuration or metastasis. 



Fig. 114. 




The infectious tracts leading from the ear into the posterior cranial fossa. (Horizontal section through 
the ear and the posterior cranial fossa.) &s, sinus sigmoideus; Se, saccus endolymphaticus; Csl, canalis semi- 
circularis lateralis: Css, canalis semicircularis superior; Csi, canalis semicircularis inferior ; Av, vestibular 
aqueduct; V, vestibulum; Mai, internal auditory meatus; T, eustachian tube; C, cochlea; Ty, tympanum; 
Mae, external auditory meatus. 

The various infectious tracts are denoted by figures. 

(1) The suppurative inflammation of the mastoid continues to the sinus sigmoideus, whence it penetrates 
into the cerebellum. 

(2) The inflammation extends from the middle-ear spaces (Ty) through the cochlear window, vestibulum, 
and cochlea, to the internal auditory canal and along the nerve tuft of the internal auditory canal into the 
cerebellum. 

(3) Suppurative otitis media with fistula of the promontory. The complication of the posterior cranial 
fossa occurs through an endocranial fistula of the cochlea. 

(4) Conveyance of the suppuration from the middle ear to the posterior cranial fossa through an endo- 
cranial fistula of the upper or posterior semicircular canal, which are likewise infected. The area of the middle 
cranial fossa may become involved by the formation of an endocranial fistula of the vertex or anterior part of 
the superior semicircular canal. 

(5) Extension of mastoid suppuration to the posterior mastoid cells in the sinus region, followed by per- 
foration into the posterior cranial fossa. 

(6) Spreading of suppurative otitis media to the posterior cranial fossa through the canalis facialis. 

(7) Otitis media leading to ulceration of the labyrinth either direct or through a fistula. The spreading 
of the labyrinth suppuration to the posterior cranial fossa takes place through the vestibulum, the vestibular 
aqueduct, and the ductus and saccus endolymphaticus. 

Cases with chronic suppurative ostitis of the temporal bone and 
those complicated by cholesteatoma are particularly dangerous in caus- 
ing cerebellar abscess, as soon as they have led to a suppurative inflam- 
matory involvement of the labyrinth and to acute suppurative disinte- 
gration of the cholesteatoma. 



ENDOCRANIAL OTOGENIC AFFECTIONS 349 

Some cerebellar abscesses are enclosed in a fibrinous capsule, but 
most of them are not. Those without a capsule are often of irregular 
shape (Fig. 116) and are provided with blind rami and sinuses. 

After an abscess of this kind has persisted for some time, it is not 
unusual for several daughter abscesses to develop in the same hemis- 
phere, in the worm, or exceptionally in the opposite hemisphere. 03dema 
and serous osmosis from the adjacent meninges occur as early changes 
in the immediate vicinity of the abscess. Later, fibrinous secretion will 
occur in the intradural space, adhesion of the meninges, or in rare cases 
extensive callosities. The anatomical result of a cerebellar abscess which 
has been left alone consists in outward perforation into the intradural 
space (Fig. 115) or into the fourth ventricle. In both cases the immediate 
consequence is fatal suppurative meningitis. 

Fig. 115. 




Girl, thirteen years old. Abscess of the'right cerebellar hemisphere (o) near the perforation, with regional 
swelling of the' right hemisphere and disC0lcira£ion"o'f the surface. 

Cerebellar abscess occurs more frequently in the second decade of 
life than in any other. 

Symptomsl— All cases occur in conjunction with an otherwise 
complicated fetid middle-ear suppuration; in chronic cases there is 
usually acute suppurative decomposition of a cholesteatoma. Inflam- 
matory mastoid manifestations are usually present in acute cases, while 
in chronic cases the mastoid may be perfectly normal. Pus retention in 
the antrum is of frequent occurrence, leading to lowering of the posterior 
wall of the osseous auditory canal or fistulous perforation. In the si- 
multaneous presence of labyrinth suppuration, which occurs in about 85 
per cent, of all cerebellar abscesses in the course of chronic middle-ear 
suppuration, all the symptoms of diffuse labyrinth suppuration (vomit- 
ing, vertigo, equilibrial disturbances, deafness, spontaneous nystagmus,, 
fistular symptoms, etc.) can be established by examination or history. 



350 



THE DISEASES OF CHILDREN 



There is nothing characteristic in the otoscopic findings, which 
rather show the various forms of the types found in complicated sup- 
puration of the middle ear. 

General Symptoms. — There are physical and psychic unrest, fatigue, 
insomnia in spite of a great desire to sleep, severe occipital headache, 
frequent vomiting of the cerebral tj^pe, and paroxysms of vertigo. 

Further early symptoms are susceptibility to pressure at the nape, 
more or less rigidity of the neck and susceptibility to percussion at the 
occiput. 



Fig. 116. 




Horizontal section through the cerebellum and the crus cerebri at the level of the corpora quadrigemina. 

Irregular, old abscess (a, a') in the right cerebellar hemisphere. Its anterior portion (a) extends to the 
surface of the hemisphere. 

Girl, twelve years old (chronic suppuration of the middle ear and labyrinth, acute exacerbation by 
streptococcus pyogenes). Death from acute suppurative meningitis. 

In advanced cases there are general debility, decrease in muscular 
power, depression, anorexia, sallow complexion, and flabbiness of the 
skin. Fetid middle-ear suppuration which has existed for a long time 
subjects the patient to malnutrition, causing an anaemic appearance. 

As to cerebellar and endocranial symptoms, cerebellar ataxia should 
be mentioned in the first place. It is characterized by disturbances of 
coordination, especially of the trunk and the lower (sometimes also of 
the upper) extremities of the affected side (hemiataxia), which can be 
recognized while standing, or walking backward and forward. They 
are, however, often concealed by equilibrial disturbances due to the 
labyrinth. Cerebellar ataxia is more distinctly demonstrated on ex- 
amining the coordination of the extremities in lateral walking. 



ENDOCRANIAL OTOGENIC AFFECTIONS 351 

Cerebellar nystagmus is very slow and coarse, in most cases straight- 
lined and horizontal. It is generally directed toward the affected side; 
the direction is changeable and nearly always attains a high degree of 
intensity. 

A cerebellar symptom of great importance consists in abducens paresis 
or paralysis of the affected side (caused by cerebral oedema or pressure of 
the abscess on the abducens nerve) and double vision. Disturbances in the 
region of the oculomotor nerve and paralysis of vision are less frequent. 

In cases which have existed for a long time there are usually opis- 
thotonos and stupor. The ocular fundus is nearly always changed, 
usually more or exclusively on the affected side. The veins are plethoric, 
but a pronounced choked disk occurs only after the abscess has existed 
for a long time and especially when it is complicated by suppurative 
meningitis. The cerebrospinal fluid is usually turbid and contains micro- 
scopic pus corpuscles. In culture it is generally sterile, pathogenic 
micro-organisms being found only in a small percentage of cases. Spasms 
of the muscles of the face, neck, and extremities are always indications 
of the cerebellar abscess having led to diffuse meningitis. 

The temperature of the body is either normal or subnormal, but 
suddenly rises considerably in the last stages of fatal cases. The pulse 
is retarded, respiration accelerated and often irregular. In advanced 
cases there are sometimes bulbar disturbances of speech and Cheyne- 
Stokes respiration. There is usually albuminuria in the final stages, 
and sometimes sugar in the urine. 

Course. — The course of a cerebellar abscess may be divided into 
four stages, like that of the temporal abscess. The initial stage is charac- 
terized by the general symptoms explained above. The predominant 
focal symptoms are obscured by the labyrinth symptoms in the presence 
of suppuration of the labyrinth. Homolateral cerebellar ataxia, if present, 
is a valuable symptom. The initial stage will last from one or two weeks 
to one or two months. In the latent stage the subjective feeling of the 
patient is good, and it requires a careful examination to demonstrate 
the existence of unilateral ataxia and disturbances of coordination of 
the extremities of the affected side. This stage lasts from a few days to 
a few weeks. The transition of the latent into the acute stage is usually 
shown by the occurrence of double vision or abducens paralysis. There 
are also all the above focal and general symptoms. This stage lasts 
from a few days to about two weeks. In the terminal stage the symptoms 
of perforated abscess or purulent meningitis prevail. 

Diagnosis. — The clinical diagnosis of cerebral abscess meets with 
considerable difficulties in all stages. 

Careful testing for cerebellar ataxia, lateral walking toward the 
affected side, abducens paralysis with double vision, may offer valuable 



352 . THE DISEASES OF CHILDREN 

guiding points. In the latent and terminal stages an exact clinical diag- 
nosis is out of the question. But it is possible in nearly all cases to estab- 
lish the presence of an affection of the posterior cranial fossa. An experi- 
enced surgeon will then be led, by the operative findings of the labyrinth, 
dura, or sinus sigmoideus, to proceed to the cerebellum and evacuate 
the abscess. 

Differential Diagnosis. — The following affections come in for consider- 
ation: (1) suppuration of the labyrinth; (2) circumscribed meningitis of 
the posterior cranial fossa; (3) extra- and intradural abscesses of the pos- 
terior cranial fossa; (4) suboccipital suppurations, which are usually of a 
tuberculous nature; (5) tumor of the auditory nerve; (6) cerebellar tumor. 

A cerebellar abscess is sufficiently differentiated from suppuration 
of the labyrinth by the presence of hemiataxia, lateral walk to the 
affected side, and the unilateral disturbances of coordination of the 
extremities. The differential diagnosis will be more difficult in a patient 
who is bedridden owing to frequent severe paroxysms of vertigo, and 
cannot be tested for standing or walking. The question, however, is 
not so much as to whether there is any cerebellar abscess or a suppura- 
tion of the labyrinth, but rather whether there is any suppuration of 
the latter alone or associated with a cerebellar abscess. If the symptoms 
of the former have already disappeared, the differentiation will be easy. 
If vertigo due to the labyrinth has already been removed by operation, 
the persistence of vertigo would point to the presence of a cerebellar 
abscess. 

Furthermore, spontaneous nystagmus is always directed toward the 
non-affected side in uncomplicated diffuse suppuration of the labyrinth, 
while the reverse is the case in cerebellar abscess. 

Cerebellar nystagmus is horizontal and very intense, while that 
occurring in diffuse suppuration of the labyrinth is coarse or fine, often 
rotatory, and, in chronic cases, of the lowest or medium degree of in- 
tensity. 

Differentiation between cerebellar abscess and circumscribed men- 
ingitis of the posterior cranial fossa or intradural (intrameningeal) 
abscess depends upon the history. Circumscribed meningitis of the 
posterior cranial fossa has no latent stage, so that the symptoms undergo 
continuous exacerbation. In cerebellar abscess, however, there are periods 
of relief and often transitory disappearance of the symptom-complex. 
It should be specially mentioned, however, that cerebellar abscesses are 
often associated with extra- or intradural abscesses of the posterior 
cranial fossa. 

Suboccipital suppuration starts from osseous foci of the base of the 
skull (occipital bone or petrous bone) or from the first two cervical ver- 
tebrae. There is usually complete rigidity of the neck, the patient being 



ENDOCRANIAL OTOGENIC AFFECTIONS 353 

unable to raise or turn his head except with the assistance of his hand. 
The differential diagnosis is still further facilitated if there is no suppura- 
tion of the ear, whether simple or complicated. As was explained above, a 
cerebellar abscess presupposes a further complication of a middle-ear sup- 
puration, notably by a suppuration of the labyrinth or a purulent affection 
of the dura in the region of the cerebellar hemisphere (dura, venous sinus). 
X-ray examination will likewise furnish exact information. 

As to a tumor of the auditory nerve, the differential diagnosis is 
only of clinical importance if in the course of growth it has led to a com- 
pression of the cerebellar hemisphere or to cerebellar symptoms. The 
most important sign is the absence of a suppurative inflammation of 
the ear in the presence of a tumor as against the presence of a chronic 
suppuration of the middle ear or labyrinth in cases of cerebellar abscesses. 
Besides, large tumors of the auditory nerve lead to early compression of 
the pons, spasms of the extremities, paresis, conjugate paralysis of vision, 
and choked disk of one or both eyes. The functional test of the internal 
ear in the presence of an auditory tumor reveals nearly always complete 
deafness and unexcitability of the static labyrinth. There are the same 
findings in diffuse suppuration of the labyrinth which may have led to 
a cerebellar abscess. Consequently, the functional test of the internal 
ear will only aid the differential diagnosis if there are still positive hear- 
ing ability and reflex excitability. Such findings are against the assump- 
tion of auditory nerve tumor. The presence of peripheral paresis of the 
facial points rather to suppuration of the internal auditory canal than 
to tumor. A facial nerve which is completely embedded in tumor masses, 
or is even adherent to the tumor, often remains capable of function. 

The differential diagnosis between cerebellar tumor (sarcoma, 
glioma, gumma) and cerebellar abscess is impossible if the tumor has 
the topographic location of the abscess and there is a suppurative affec- 
tion of the ear. The differentiation between cerebellar tubercles and an 
abscess is equally impossible under similar circumstances. In most 
cases, however, a cerebellar tumor leads to bilateral cerebellar ataxia, 
bilateral abducens paralysis, and choked disk, while the etiologically 
important middle-ear suppuration is absent. 

Treatment. — This consists in the operative exposure of the posterior 
cranial fossa, division of the dura, opening of the cerebellar hemisphere, 
and evacuation of the abscess. It is advisable in operating to follow the 
track of the suppuration. It is necessary, therefore, in all cases of laby- 
rinthogenic cerebellar abscess that the radical operation be followed by 
resection of the ulcerated labyrinth previous to opening the posterior 
cranial fossa. 

Cerebellar abscesses which have developed from a deep extradural 
abscess of the posterior cranial fossa or from thrombophlebitis of the 

VI— 23 



354 THE DISEASES OF CHILDREN 

sinus sigmoideus are best opened from the region of the sinus and from 
the part of the dura between the sinus and labyrinth, provided the latter 
is intact. 

The incision of the posterior cranial fossa should be as deep as pos- 
sible, so as to prevent retention of pus at the base of the abscess cavity 
or at the fundus of the cranial fossa, and to enable the operator to open 
and drain the abscess at its lowest point. The abscess cavity is then 
loosely packed with iodoform wick. The first change of bandage should 
take place on the second day after operation. 

Postoperative Prognosis and Course. — The operative success in 
otitic cerebellar abscesses is by no means satisfactory as yet, there still 
being a mortality of about 40 per cent. It is only exceeded by otitic 
meningitis among all other otitic endocranial affections. The prognosis 
is much less favorable than that of abscess of the temporal lobe or pyse- 
mic sinus thrombosis. This is explained by the fact that in nearly all 
cases a cerebellar abscess is not the only endocranial otogenic affection in 
a given case. In most cases chronic middle-ear suppuration is compli- 
cated not only by the cerebellar abscess, but also by suppuration of the 
labyrinth, circumscribed meningitis, or sinus thrombosis, affections 
which in themselves are of a serious nature. This is aggravated by the 
long duration of the initial stage. During this period the nutrition of 
the patient has considerably suffered, so that the operation must be per- 
formed upon debilitated, under-nourished individuals with slight power 
of resistance. 

The operation itself is a serious matter, especially if the opening 
of the posterior cranial fossa is to be combined with resection of the laby- 
rinth or with opening and evacuating the sinus sigmoideus. The after- 
treatment is also a difficult one, there being danger of pus descending 
to the bottom of the posterior cranial fossa, with consequent diffuse 
purulent meningitis. This danger exists for weeks after the operation. 
Even in favorable cases there is danger of a permanent cerebellar pro- 
lapse. No doubt, this could be removed in part and replaced by skin 
plastic, but this is always accompanied by the danger of a fresh abscess 
if the first abscess has healed with a cystic scar. There is also danger of 
diffuse meningitis setting in years afterward. 

The mortality of 40 per cent, is based on all the cases that have 
come under my observation. It also includes those cases in which 
cerebellar abscess was not diagnosticated and death occurred after per- 
foration of the abscess and suppurative meningitis. 

The comparatively most favorable prognosis is offered by abscesses 
that have been operated upon in the latent stage. They are usually 
discovered at the time of a radical operation carried out during that 
period when the operative findings have rendered the exposure of the 



ENDOCRANIAL OTOGENIC AFFECTIONS 355 

posterior cranial fossa necessary, or a complicated suppuration of the 
labyrinth has rendered a resection of the labyrinth necessary. If under 
these circumstances the dura of the posterior cranial fossa has been 
exposed, a spontaneous evacuation of the abscess through a dural fistula 
into the operative cavity may terminate favorably. 

LUMBAR PUNCTURE AND ITS SIGNIFICANCE IN OTOLOGY 

Lumbar puncture, which was recommended in 1891 by Quincke as 
a diagnostic and therapeutic measure, has been adopted in otology. 

Technic. — The instrument used is a hollow needle, the short pointed 
end of which is ground in the shape of a trocar. It is provided with a 
stylet, at the end of which there is a mark which will enable the operator 
to recognize the position of the stylet when introduced. The needle is 
closed with a metal stopper. The needle is from 8 to 14 cm. long and 
from 0.6 to 1.5 mm. wide. It is advisable to have in readiness several 
needles of different dimensions. The patient lies on one side with legs 
flexed and drawn up, so that the elbows will approach the knees as closely 
as possible. The spinal cord will thus bulge out convexly. The needle is 
introduced about- 1 cm. away from the median line between the third 
and fourth or the fourth and fifth lumbar vertebrae. As the infantile 
conus medullaris is located at the level of the third lumbar vertebra, 
there is no danger of injuring the medulla. In order to find the correct 
point of insertion, it may be convenient to connect the highest points of 
both iliac crests by a straight line which will traverse the spinous process 
of the fourth lumbar vertebra. 

A slight resistance will be felt, when the needle is introduced cor- 
rectly, in penetrating the layer of muscles and ligaments. This resis- 
tance will cease as soon as the needle has advanced to the vertebral 
canal. The needle is firmly fixed if inserted correctly; if, however, it 
can be moved to and fro in the tissue, the right way has not been found. 
As soon as the operator is under the impression that the point of the needle 
has penetrated into the vertebral canal, the stylet is withdrawn and the 
exuding liquor caught in three sterile test-glasses. While passing from 
one glass to the next, the needle is closed with a metal stopper, so that 
all the fluid may be saved for the examinations. Under ordinary pres- 
sure conditions, 10-15 c.c. should be secured. With reduced pressure, 
the quantity withdrawn should not exceed 8-10 c.c; with increased 
pressure, 30-50 c.c. may be evacuated without danger. The needle is 
then rapidly withdrawn and the puncture immediately closed with an 
iodoform gauze plaster. 

The proceedings are best conducted under ether inhalation. Should 
a blood-vessel be injured, there may be pure blood at first, and the first 
portion of cerebrospinal fluid will still have an admixture of blood. This 



356 THE DISEASES OF CHILDREN 

should be caught in a special test-glass, as the fluid used for examination 
may not contain any admixture of blood. In some cases the puncture 
will give entirely negative results with the patient in the lateral decu- 
bitus. The experiment may then be repeated in the sitting or gibbous 
posture. Aspiration, in the event of there being no spontaneous evacu- 
ation, is to be strongly deprecated. The cause of a negative result may 
be faulty technic, pathological conditions in the vertebral canal or cere- 
bral cavity, such as occlusion of the foramen Magendie, viscid, purulent 
secretion in the vertebral canal, circumscribed spinal meningitis with 
agglutination or adhesions of the soft meninges, or temporary negative 
pressure in the vertebral canal. Untoward consequences have never 
been reported in auricular or intracranial otitic affections, provided the 
puncture has been carried out with care. The puncture is, of course, 
contraindicated when the affection is complicated by a disease in which 
the puncture would always involve danger, as in diabetes, ursemia, 
cerebral tumor, or injury to the skull. 

Clinical Examination of the Cerebrospinal Fluid 

(1) Pressure. — In order to measure the pressure under which the 
fluid escapes, many authors have recommended the use of a manometer. 
The use of auxiliary apparatus, however, always includes the danger of 
infection, and, besides, the pressure varies considerably during the opera- 
tion and greatly depends upon accidental causes, such as position of the 
body and cardiac function. A manometer may, therefore, well be dis- 
pensed with, and I content myself with estimating the pressure accord- 
ing to whether the fluid escapes in a strong gush, in an arch, slowly, or 
in driblets. Increased or considerably decreased pressure always points 
to considerable pathologic changes. In meningitis the pressure often 
remains unchanged. 

(2) Color. — Normal cerebrospinal fluid is colorless. Yellow dis- 
coloration occurs in chronic non-suppurative meningitis, in arterio- 
sclerosis of the cerebral arteries, in epilepsy and paralysis. Red dis- 
coloration occurs in pachymeningitis hemorrhagica, in cerebral or 
ventricular hemorrhage, and in accidental admixture of blood from 
injury to the blood-vessels during puncture (see above) . In the absence 
of any purulent inflammation of the brain or spinal cord the following 
rules hold good for the differential diagnosis, whether the admixture of 
blood be accidental or pathological: 

In pathological admixture the blood is deposited at the bottom of 
the undisturbed test-tube without coagulation. In admixture of blood 
from an accidentally injured vessel there will be coagulation of the 
deposit. Considering that, in many cases of meningitis, diagnosticalty 
valuable coagulation occurs due to the inflammatory process itself, it 



ENDOCRANIAL OTOGENIC AFFECTIONS 



357 



is clear that fluid containing accidental admixture of blood is of no value 
for deciding the question as to whether an affection is meningitis or not. 
For this reason the fluid should be caught in several tubes, so as to obtain 
pure fluid in the end. Should this prove impossible, another puncture 
may be made at a different place, or repeated on another day. There 
is hardly ever a question of hemorrhagic processes in otitic cerebral 
affections, so that, in the event of a blood-stained fluid appearing in 
otitic endocranial processes, an accidental admixture of blood may 
always be assumed. This can also be recognized by the discoloration 
becoming less intense, or the fluid becoming clear, with subsequent 
withdrawals either at the original or a new point of puncture. 



Fig. 119. 



Fig. 117. 



Fig. 118. 





Minute, cobweb-like coagu- 
lations of spinal fluid in tu- 
berculous meningitis in a 
one-year-old child. 



Typical columnar coagula- 
tion with adhesive threads at 
the top and bottom of the test- 
tube, in suppurative diplo- and 
staphylococcus meningitis. 




Conical coagulation ending 
in a point, in suppurative 
meningitis (streptococcus 
pyogenes). 



(3) Transparency. — Normal cerebrospinal fluid is as clear as water. 
Gray, yellow-gray, or yellow-green discoloration is always a sign of 
purulent meningitis. In serous meningitis and in many cases of the 
tuberculous form the fluid is perfectly clear. 

(4) Coagulation. — In meningitis there are fibrinous coagulations 
in the course of six to twenty-four hours in the undisturbed test-tube; 
in tuberculous meningitis they are exceedingly fine and in the shape of a 
cobweb permeating the entire fluid (Fig. 117), or they can be recognized 
as minute white specks suspended in the fluid or deposited at the bottom. 
In suppurative discoloration of the fluid the coagulation in the test- 
tube is either in the shape of a column (Fig. 118) or of a cone (Fig. 119), 
the column often inserted in threads both at the surface meniscus and 
at the bottom of the tube. Upon adding sodium citrate or oxalic acid 
to the freshly withdrawn fluid there will be no coagulation. 



358 THE DISEASES OF CHILDREN 

(5) Chemical Changes. — Normal fluid contains albumen only in 
traces. It contains no sugar, or only in traces (0.06-0.09 per cent.). 
An increased percentage of albumen is often found in cases of menin- 
gitis and cerebral tumors (1-2 per cent.). In tumors especially of the 
posterior cranial fossa the sugar content may be considerably increased. 
In diabetic coma aceto-acetic acid is sometimes found in the cerebro- 
spinal fluid. 

(6) Cytology. — The sediment, obtained with or without centri- 
fuging, is put upon the slide by means of a pipette, and fixed by heat or 
alcohol ether. Staining is done with tri-acid, hematoxylin eosin, or 
after Romanowsky. The cytological examination should be made 
immediately after puncture and before coagulation. Should the latter 
have set in, the fluid is shaken with glass pearls until a uniform tur- 
bidity, or nearly so, has been obtained. The centrifuged sediment of 
normal cerebrospinal fluid contains only isolated lymphocytes. 

In suppurative cerebrospinal meningitis there are polynuclear and 
large mononuclear leucocytes, together with normal white blood-cells. 
The lymphocytes in tuberculous meningitis are of particularly small 
size. Lymphocytosis is also present in all syphilitic and metasyphilitic 
affections of the brain and spinal cord ; in the cerebral and spinal meninges 
likewise (paralysis, tabes). 

Flaky blood pigment is a sign of old hemorrhages (cerebral trauma, 
pachymeningitis hsemorrhagica) . 

(7) Bacteriology. — In suppurative meningitis the pathogenic factors 
should be demonstrated first in the microscopic preparation, after which 
they should always be verified as pathogenic by cultures and animal 
experiments. It is not a rare occurrence for staphylococci, Gram-posi- 
tive cocci, or diplococcus intracellularis to be microscopically demon- 
strable and yet to prove negative both in cultures and animal experi- 
ments. These are cases of impurities imparted to the fluid, especially 
when staphylococci are present, or bacterial impurities of the staining 
fluid, or of cerebrospinal fluid containing degenerated bacteria which 
are no longer pathogenic. In many cases of intracranial otitic affec- 
tions where the cerebrospinal fluid is gray or turbid from pus, the fluid 
proves perfectly free from micro-organisms. These cases of purulent 
non-infectious meningitis are found in imperforate cerebral abscess and 
in extensive pus foci of the external dural surface (extradural abscess, 
ichorous sinus thrombosis). Again, in the early stages of suppurative 
infectious meningitis, the cerebrospinal fluid may be still sterile, while 
a later puncture will yield fluid containing pathogenic micro-organisms. 
In circumscribed purulent meningitis the fluid may remain perfectly 
clear and sterile for a considerable time. It is only in exceptional cases 
that clear non-bacterial fluid is observed in the early stages of circum- 



ENDOCRANIAL OTOGENIC AFFECTIONS 



359 



scribed suppurative pachymeningitis and intrameningeal abscess. In 
tuberculous meningitis it is advisable to make a bacteriological exami- 
nation of the cobweb coagula. If spontaneous coagulation does not 
occur, or if it is inconvenient to wait for it, a small piece of cotton wool 
may be placed in the liquid, as this will be rapidly surrounded by co- 
agulations. According to Ziehl, tubercle bacilli can be demonstrated 
in about 75 per cent, of all tuberculous cases, but it may be necessary 
to prepare a large number of specimens. If the microscopic demon- 
stration is unsuccessful, animal experiments should be resorted to, 
according to Bloch. When using guinea-pigs, the best way is to injure 
the inguinal lymph-glands by crushing. This will predispose them to 
tuberculous infection. A few c.c. of the cerebrospinal fluid to be tested 
are injected into "the glands, which in positive cases will show tuber- 
culous infection in one or two weeks. 

• The following table will illustrate the total findings of cerebrospinal 
fluid both in normal cases and in the various forms of otitic meningitis : 

CEREBROSPINAL FLUID 



Diagnostically important 
properties of cerebro- 
spinal fluid 


Endo- 
cranium 
normal 


Serous 
meningitis 


Suppura- 
tive non- 
infectious 
meningitis 


Suppurative 
infectious 
meningitis 


Tuberculous 
meningitis 


Admix- 
ture of 
blood 


Pressure 

Color 


Normal 

Colorless 

Clear 

None 

L 

Negative 


Increased 

Colorless 

Clear 

Present 

L 

Negative 


Normal or 
increased 

Gray 

Turbid 

Present 

LP 

Negative 


Normal, 
elevated or 
decreased 

Gray or 
yellow 

Turbid 

Present 
LP 

M 


Normal 

Colorless 
or gray 

Clear or 
turbid 

Present 

LP 

Tbc 


Normal 
Reddish 


Transparency 

Coagulation 

Cytological findings. . . 
Bacteriological 
findings 


Turbid 

Present 
LE 

Negative 



L — Lymphocytes. P — Polynuclear leucocytes. 
M — Micro-organisms. E — Erythrocytes. 
Tbc— Tubercle bacilli. 

The high diagnostic value of lumbar puncture is indisputable, as it 
furnishes the only reliable means of learning the exact condition of the 
meninges in a given case. Its indicational value, however, is only of sub- 
ordinate importance, as an operation cannot be regarded as devoid of 
success even when the cerebrospinal fluid shows the gravest changes 
and demonstrates the presence of infectious, purulent, diffuse menin- 
gitis. A contraindication to operation can only be found in the general 
manifestations, an unfavorable condition of the heart and respiration, 
but never in the findings of lumbar puncture. Besides, operation in 
all these cases is urgent, so that it would be out of the question to wait 
for the culture or animal test. In most cases lumbar puncture is carried 
out as a preliminary act to the operation or immediately afterward. 



360 THE DISEASES OF CHILDREN 

The idea of abstaining from an operation just because the spinal fluid 
is turbid from suppuration has been entirely discarded. 

Lumbar puncture is employed as a therapeutic measure in the after- 
treatment of operative cases of otitic meningitis, and many authors 
have applied it with some degree of success in non-suppurative affec- 
tions of the internal ear, in cases of obstinate subjective noises or vertigo. 
In these cases the puncture is best carried out under the influence of 
ether inhalation, and repeated at not too frequent intervals according to 
the nature and course of the affection. 

Ventricular puncture can be best carried out after operative ex- 
posure of the middle cranial fossa in cases of intracranial otitic affections 
where lumbar puncture has not yielded any fluid or not a sufficient 
amount of it. 

Ventricular puncture is contraindicated if perforated cerebral abscess 
is suspected. 

Lange in 1912 demonstrated that the action of cerebrospinal fluid in 
various conditions upon a colloidal gold solution could be used as a 
delicate test, differentiating normal from pathological cerebrospinal 
fluids, and more particularly syphilitic from other affections of the central 
nervous system. 

The theory of the reaction is based upon the following observations 
made by Zsigmondy in the course of his study on metallic colloidal 
solutions : 

1. Solutions of electrolytes precipitate colloidal gold. 

2. Proteins in the absence of an electrolyte also precipitate a solu- 
tion of colloidal gold. 

3. Proteins in the presence of an electrolyte inhibit precipitation in 
colloidal gold solution, the so-called "Gold-Schutz." 

The relation existing between this opposed reaction of electrolyte 
and protein is definite for the same protein but differs when a different 
protein is used, and is therefore a specific property of the individual 
protein. 

Lange's application of these principles to the study of spinal fluids 
is based upon the theory (1) that substances in pathological spinal fluids 
will precipitate colloidal gold provided the globulin and nucleoprotein 
fractions are held in solution with a 0.4 per cent, sodium chloride solu- 
tion, and (2) that there is a characteristic change for certain diseases 
involving the central nervous system. 

The test is a delicate one and its success depends upon the use of 
scrupulously clean glassware, accuracy in all measurements, and avoid- 
ance of bacterial contamination. The presence of blood or serum vitiates 
the findings. 



XIV. TRAUMATIC INJURIES OF THE ORGAN OF HEARING 1 

Isolated traumatic injuries of the chain of auricular ossicles are only 
seldom observed. These are caused almost exclusively by foreign bodies 
in the auditory canal which have advanced into the middle ear by 
unsuccessful attempts at extraction. Aside from rupture of the tympanic 
membrane, there may be luxation of the auricular ossicles, fracture of the 
neck of the malleus, tearing of the chorda tympani, hemorrhages of the 
middle ear, and inflammatory changes in the region of the middle ear. 

Traumatic fissures and fractures of the temporal bone in childhood 
are of the greatest rarity, owing to the great elasticity of the cranial 
bones. 

The cause of acquired deafness is often stated to be a fall on the 
head, but the exclusive cause is meningitis. It may be that the child 
fell out of bed during convulsions, landing on his head, or that the symp- 
toms of cerebrospinal meningitis had not previously been noticed by the 
parents, and the fact of his suddenly falling down was erroneously 
regarded as the cause of the affection. 

Fractures of the temporal bone in childhood are part manifestations 
of serious general injury, and will only occur under employment of con- 
siderable force. 

The local signs of fissure and fracture in childhood do not differ 
from those of the adult. Fissures of the tegmen tympani lead to accum- 
ulation of blood in the middle-ear spaces (haematotympanum), and 
otoscopic examination shows black-red discoloration of the tympanic 
membrane which bulges strongly outward. 

Fractures of the upper wall of the auditory canal and the tympanic 
roof lead to traumatic tearing of the membranous auditory canal. Ex- 
amination shows effusion of blood from the external meatus. The 
tympanic membrane is usually covered by blood coagula and is not 
visible through the otoscope. If the fracture of the temporal bone has 
also caused tearing of the dura, there will be evacuation of cerebro- 
spinal fluid through the external auditory meatus. In most cases fluid 
will only escape after the blood has been expelled, often as late as one 
or two days later. Fractures of the petrous bone which take their way 
through the labyrinth are apt to cause deafness rapidly with acute symp- 
toms (labyrinthine vertigo, equilibria! disturbances, and vomiting). In 
a few cases facial and abducens paralysis have been observed. 

x The traumatic injuries of the external ear have been discussed on p. Ill, those of the 
tympanic membrane on p. 128. 

361 



362 THE DISEASES OF CHILDREN 

Course. — Fractures of the temporal bone through the labyrinth 
cause permanent deafness. Paralysis of the facial nerve is usually 
completely cured. The middle ear will undergo healing under gradual 
resorption of the blood, provided no secondary infection occurs. Should 
such occur, there will be suppurative disintegration of the coagula 
accumulated in the middle-ear spaces and suppurative otitis media. 
Complication by traumatic meningitis renders the prognosis very un- 
favorable. 

Treatment should include rest in bed and application of ice -bags to 
the head. In examining the ear nothing should be done but carefully 
removing the coagula from the auditory canal and applying a bandage 
over the ear. Any other manipulations should be refrained from, such 
as syringing, air insufflation, etc. If vertigo should persist, the auditory 
nerve should be treated with the galvanic current, producing galvanic 
nystagmus in the opposite direction to the prevailing pathologic one. 

In the light forms of traumatic concussion of the labyrinth following 
a direct or indirect injury to the skull, there is usually some difficulty 
of hearing. Manifestations of the static labyrinth may be entirely 
absent or consist in slight spontaneous nystagmus without vertigo. 
The prognosis is favorable, and after a short time recovery usually 
takes place with perfectly normal hearing ability. 

In cases of serious traumatic concussion of the labyrinth there is 
considerable impairment of hearing, or deafness; in most cases there are 
also pronounced irritative manifestations of the static labyrinth, con- 
sisting in vertigo, equilibrial disturbances, and vomiting, which will 
gradually disappear. Healing in the region of the static labyrinth often 
occurs with maintained reflex excitability of the labyrinth, its complete 
loss being rare. Deafness will persist unchanged. Where hearing abil- 
ity is preserved, the cases show a different behavior; in some few the 
hearing acuity is improved in the course of time, in others the degree of 
impaired hearing remains constant, and in a third group the difficulty of 
hearing gradually increases and may lead to complete deafness. 



XV. MALIGNANT NEW-FORMATIONS OF THE EAR 

Carcinoma of the auricular region is extremely rare in children. I 
have observed a single case, where a young man sixteen years of age had 
inoperable carcinoma of the middle ear. This undoubtedly started from 
the glands of the auditory canal and developed, like all middle-ear car- 

Fig. 120. 




Sarcoma of the external ear and middle ear, starting from a small spindle-cell sarcoma of the parotid. Girl, 

fourteen years of age. 

cinomata, from a chronic suppuration of the middle ear. I saw the 
patient at a time when the entire temporal bone was infiltrated by carci- 
nomatous masses, the entire auricular region bulging out convexly, and 
the carcinoma had caused paralysis of the facial nerve through erosion 
of the capsule of the labyrinth. Leideler observed a middle-ear carci- 
noma in a young man of nineteen. 

363 



364 THE DISEASES OF CHILDREN 

Sarcoma of the ear occurs less often in childhood. These are either 
cases of subacute leukaemia which have developed a lymphosarcoma, 
originating at the cervical glands, destroying the base of the petrous 
bone, and penetrating into the middle ear or external auditory meatus, 
or cases where the tumor has developed from a tonsillar or parotid 
sarcoma (sarcomatous mixed tumor, small-celled round- or spindle-cell 
sarcoma; Fig. 120). Sarcoma of the ear emanating from the dura is 
very rare in youth. 

Course. — Sarcoma causes in a very short time fetid suppuration of 
the middle ear, extensive ulcerations of the external auditory meatus, 
and paralysis of the facial nerve. Unless the original affection leads to 
death, the latter will in most cases be due to suppurative meningitis 
consequent upon spreading of the suppurative middle-ear affection to 
the endocranium, or owing to loss of blood consequent upon erosion of 
the carotid, sinus sigmoideus, or bulbus jugularis. 

The prognosis is unfavorable in all cases. 

Treatment. — The conservative treatment of sarcoma consists in 
careful exposure to the X-ray or radium, in regard to which an experi- 
enced X-ray specialist should be consulted. 

Operative interference is contraindicated in leuksemic or lympho- 
sarcomatous tumors, as the operative trauma and after-treatment only 
seem to hasten the end. Sudden occurrence of laryngeal stenosis in 
case of tonsillar sarcoma may render tracheotomy necessary. Sarcoma 
which has originated from parotid tumors is the only form which admits 
of surgical interference as long as the tumefaction is confined to the 
external ear and the middle ear is perfectly intact; but even in these 
cases the chances of permanent recovery are small. 

In the rest of the cases there is nothing to be done but resort to 
symptomatic general treatment, and local treatment of the fetid middle- 
ear suppuration which will set in as soon as the tumor spreads to the 
middle ear. 

The patient must be made comfortable, especially in later stages 
of the disease, by morphine. Lysol irrigation does much to control the 
disagreeable odor of the necrotic bone. 



XVI. AFFECTIONS OF THE EAR IN GENERAL DISEASES 

I. AFFECTIONS OF THE EAR IN DISEASES OF THE BLOOD AND THE BLOOD- 
FORMING ORGANS (LYMPHOMATOUS EAR DISEASES. AFFECTIONS 
OF THE ORGAN OF HEARING BY LEUKEMIA, CHLOROMA, 
AND KINDRED DISEASES) 

Lymphomatous ear diseases and their pathological manifestations 
are principally favored by the hemorrhagic diathesis. Hemorrhages 
of the ear occur in a large number of cases, especially in those where 
hemorrhages also occur in other parts of the body. Bleeding from the 
ear occurs particularly in those forms of acute lymphomatosis which 
are apt to develop from acute hyperaemia of the auricular region, the 
base of the skull, or the entire head. Bleeding of the middle ear leads to 
hsematotympanum and, owing to bacterial infection, to hemorrhagic sup- 
puration of the middle ear under considerable elevation of temperature. 

Circumscribed hemorrhages of the labyrinth lead to complete deaf- 
ness and loss of reflex excitability of the labyrinth, either by way of vari- 
ous single attacks or without any warning. Apoplectiform hemorrhages 
of the labyrinth may lead to destruction of the entire neuro-epithelium. 
Sudden effusion of viscid blood from the labyrinth may lead to compres- 
sion of the membranous labyrinth; slow effusions, often repeated, to 
partial obliteration of the membranous labyrinth. Hemorrhages have 
also been observed in the internal auditory canal and along the nerve- 
sheaths of the auditory and facial nerves. Blood effusions of the aque- 
ducts or internal auditory canal destroy the normal lymph circulation 
of the internal ear, which may again lead to ectasia of the membranous 
labyrinth. Continued bleeding of the labyrinth causes secretion of 
large quantities of pigment in the labyrinth. 

Lymphoid infiltration is found in the tympanic cavity and the 
mucous membrane of the tube, and often in the perilymphatic connec- 
tive-tissue layer of the internal ear, sometimes in the stria vascularis, 
in the ligamentum spirale, in the cms cerebri, and the root region of 
the octavus. 

The inflammatory changes consist in small-celled, apparently lym- 
phomatous infiltrates, which later disintegrate by suppuration and are 
permeated by micro-organisms. 

Acute exudation of the labyrinth is only found in the early stages 
of hemorrhagic labyrinthitis. 

In cases of prolonged duration secondary changes of the labyrinth 
and middle ear may occur in the shape of pathological connective- 

365 



366 THE DISEASES OF CHILDREN 

tissue and bone proliferations, and degenerative atrophy of the sensory 
epithelium and of the peripheral and central branches of the auditory 
nerve. I have also found lymphoid tumefaction of the labyrinth in 
cases of leukaemia in the presence of lymphosarcoma and chloroma. 
Hyperaemia of the ear is exceedingly common in lymphomatosis. Anae- 
mia of the ear, notably of the labyrinth, is the result of connective- 
tissue obliteration of blood-vessels following hemorrhages of the laby- 
rinth or after displacement of regional small arteries through lymphoid 
tumors. 

The diagnosis usually offers no difficulties. In all cases of hemor- 
rhagic otitis or when hemorrhage of the labyrinth is suspected it is 
advisable to examine the blood microscopically. 

Treatment. — There can, of course, be no other treatment but 
symptomatic. Hemorrhage from the external meatus should be thor- 
oughly wiped out with cotton tips and controlled. by insufflation of iodo- 
form powder and insertion of iodoform gauze. The same applies to 
hemorrhagic otitis. The treatment of inflammatory changes of the 
tympanic cavity and mastoid does not differ in any way from that in 
non-lymphomatous forms. In mastoid affections the possible necessity 
of surgical interference should not be lost sight of. 

Transitory improvement sometimes sets in spontaneously. The prog- 
nosis of lymphomatous affections of the internal ear, and particularly that 
of apoplectiform deafness caused by hemorrhages, is unfavorable. 

II. CONSTITUTIONAL EAR DISEASES 
1. AFFECTIONS OF THE EAR IN LYMPHATIC CONSTITUTION AND RHACHITIS 

So far as the affections of the external ear are concerned, mention 
may be made of obstinate eczema of the concha and external auditory 
meatus. Lymphatic individuals very frequently suffer from catarrhal 
affections of the middle ear. Suppurative otitis media is also often 
observed. In this class of patients there is a tendency to develop a 
chronic state of both catarrhal and suppurative middle-ear affections. 
Older lymphatic children often suffer from neurasthenic troubles of the 
ear, disagreeable subjective noises, or hallucinations of hearing. Some of 
them are much molested by the subjective noises (humming) of the 
cervical veins, which are often unilateral, but may be bilateral. 

General invigorating treatment is of the greatest importance in 
conjunction with local treatment. 

Owing to impaired communication between periosteum and bone, 
subperiosteal and extradural abscesses may insidiously develop in lym- 
phatic individuals and attain a considerable size. Subperiosteal ab- 
scesses of the mastoid may under these circumstances extend to the 
vertex and middle of occiput, or even beyond the median line to the 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 367 

other cranial hemisphere. Owing to perforation of abscesses through 
the osseous wall of the auditory canal, the membranous part of the canal 
may be completely bathed in pus, and the suppuration may spread to 
the submaxillary articulation and the soft parts of the mouth. 

Among the intradural abscesses in lymphatic patients, the very 
extensive abscesses at the base of the posterior cranial fossa and the 
large abscesses in the projection of the tympanic roof and the temporal 
squama are most known and dreaded. 

In rhachitic children there are characteristic arrests of develop- 
ment of the temporal bone. The cortical layer is especially thin and 
porous. The fissura mastoidea of older children may still contain car- 
tilaginous remnants corresponding to the lateral wall of the antrum. In 
suppurative inflammation there is danger of a rapid spreading of the 
suppuration to the bone and rapid suppurative resorption of the latter. 
In suppurative inflammation of the antrum there is rapid perforation 
outward, with formation of a subperiosteal abscess of the mastoid region. 
The petrous bone may still have an exceedingly tender and apparently 
diploic structure in advanced childhood, so that middle-ear suppura- 
tion in rhachitis may lead in an incredibly short time to a suppuration 
of the petrous bone, either with paralabyrinthine pus foci or necrosis 
of the petrosis bone and labyrinth. 

2. DISEASES OF THE EAR IN ENDEMIC CRETINISM. ENDEMIC CONSTITU- 
TIONAL DYSACUSIS (DIFFICULTY OF HEARING) AND DEAFNESS 

The following statements are based upon the experience I have 
gathered in the study of the material collected and treated by von Wag- 
ner. This material comprises. the district of Judenburg in Styria, where 
endemic cretinism is particularly rampant. I commenced my investiga- 
tions in 1904 and since then have uninterruptedly continued. 

Occurrence. — Difficulty of hearing, or dysacusis, is exceedingly 
frequent in cretinism. Examination of considerable material has shown 
that hardlv one-fourth of all cretins are endowed with normal hearing 
acuity. In most cases there is a medium reduction, in 20-30 per cent, 
of those partly deaf there is a high degree of reduction, and in about 5 
per cent, there is complete deafness. 

The ear affections of most cretins are congenital or have existed 
from earliest infancy. In other cases they develop, like the other cre- 
tinic symptoms, after acute infectious diseases and other serious general 
affections, or at least become more accentuated than before, or they occur 
without such additional factors. Cretinic deafness, however, is always 
congenital, as are all the other cretinic signs of a grave nature. 

Bircher proposed to designate as "endemic deafness" that form of 
deaf-mutism which is peculiar to endemic cretinism and frequently 



368 THE DISEASES OF CHILDREN 

characterizes it as apart from all other forms of deafness. Bircher's 
endemic deaf-mutism corresponds with Hammerschlag's endemic con- 
stitutional deafness. Bircher points out the various degrees of physical 
and mental development in deaf-mute cretinism, stating, "There are 
such as are well developed in all respects aside from the absence of hear- 
ing and speaking, while others show all degrees of physical and psychic 
decadence." 

Bloch established the conception of "dysthyral deafness," based 
upon the material he collected. He emphasizes the frequency of medium 
reduction of the acuity and of lingual disturbances. He also mentions 
the favorable effect of thyroid feeding upon the deafness of cretins. 

Siebenmann attacks the conception of "dysthyral" deafness, stat- 
ing that in a case of total aplasia of the thyroid the ear and particularly 
the labyrinth were anatomically intact. According to my opinion, this 
proves nothing. Among the large material I have examined, I have 
here and there found fairly good intelligence and good hearing acuity, 
although there was no demonstrable thyroid; in some of these cases, at 
least, the labyrinth was intact. True, . Bloch has found changes of the 
labyrinth in a far greater number of cretins than myself, and admits 
that dysthyral difficulty of hearing is not very frequent or even always 
considerable. He refers to cases of impaired hearing of the lightest 
degree in which hypothyroids never were conscious of their defect and 
where the latter could only be detected by careful examination of the 
ear. Possibly Bloch includes in his nomenclature various pathological 
forms which do not belong together either anatomico-pathologically or 
etiologically. Nevertheless, Bloch's conception may be accepted, led 
by the impression gained from the observation of considerable cretinic 
material, and in view of the fact that there are very many goitrous cre- 
tins with defective hearing and many cases of considerable dysacusis 
and deafness in hypo- and athyroid cretins. 

Kocher assumes a central seat of deafness and speaks of an auricular 
sensory aphasia. 

Von Wagner distinguishes between certain types of cretins. The 
dwarfish cretin is characterized by the presence of all cretinic symptoms : 
dwarfish structure, high degree of myxcedema, complete absence of 
sexual development. In these cases there is hypothyroidism, there 
being only a small atypical goitrous nodule or even no trace of that. 
This type includes many cases of fully developed idiocy, dysacusis, or 
complete deafness. Cretins without any appreciable hearing defect 
and with good intellect are rare in this class. 

In other types of cretinism the principal sign is endemic deaf- 
mutism. There are serious disturbances of the organ of hearing or total 
deafness, together with considerable impairment of psychic functions. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 369 

Among the dwarfish half-cretins slight affections of the middle ear 
and labyrinth are not infrequent, while serious disturbances or deafness 
do not exist. 

In the type of the cretinic dwarf characterized by dwarfish stature, 
myxcedema, and infantile genitals, there are no appreciable disturbances 
of intellect or hearing. 

A very frequent type of cretins comprises those with a very pro- 
nounced goitre. In these cases, in which all other cretinic signs are 
overshadowed by the goitre, there is hardly one with normal hearing, 
but complete deafness is rare. This group includes both half-cretins 
and full cretins, cases with slight and with considerable hearing defects; 
deaf-mute cretins and half-cretins likewise belong to this group. The 
last type is characterized by deaf-mutism and goitre. In these cases 
there is no arrest of growth, no cretinic expression, no myxcedema, and 
no defective genitals. Nor is their intelligence materially disturbed, 
but there is a certain degree of mental dulness and heaviness in nearly 
all cases. 

Anatomy. — Catarrhal changes of the middle-ear spaces are the 
cause of dysacusis in a large number of cases. Considerable enlargement 
of the faucial tonsils and chronic thickening and swelling of the naso- 
pharyngeal mucosa are exceedingly frequent in cretins. The catarrhal 
changes of the middle ear originate from the nasopharyngeal changes, 
typical forms of exudative middle-ear catarrh being only found excep- 
tionally. The frequency of middle-ear affections in cretins is also depen- 
dent upon the fact that the myxomatous swelling of the nasopharyngeal 
mucosa is communicated to the mucosae of the tube and tympanic 
cavity. 

Moos has found bilateral hyperostosis of the posterior and interior 
wall of the tympanic cavity in a case of idiocy (fetal chondrodystrophy) . 

Hammerschlag found in a dwarfish girl reduction of the left middle- 
ear spaces and a rigid connection between the stapes and incus. The 
shanks of the latter were coarse and the plate was reduced to one-third 
of the normal size. 

Siebenmann, in a case of aplasia of the thyroid which he examined 
anatomically, found no changes that could have occasioned any material 
functional disturbance of hearing. In another case Siebenmann found 
Corti's organ to be in a lower position than usual, while the tunnel space 
was particularly large. 

Habermann noticed arrest of development in Corti's organ and 
displacement of the cells of the spiral ganglion. 

Manasse demonstrated changes of the auricular skeleton and 
membranous labyrinth. He looks upon the changes of the bone as 
primary and congenital, and those of the soft parts as secondary. 

VI— 24 



370 THE DISEASES OF CHILDREN 

Suppurative inflammatory changes of the middle-ear spaces are 
rather rare in cretinism. Those few cases of chronic middle-ear sup- 
puration which I have observed belong to the group of suppuration 
following acute infections. In these cases the middle-ear inflammation 
had set in after scarlet fever, measles, and diphtheria. 

The changes of the internal ear consist in many cases in degenera- 
tive atrophy of the auditory nerve and the nerve-endings of the laby- 
rinth. In some cases the nerve terminations of the static labyrinth as 
well as Corti's organ are involved in the atrophic process. In other 
cases the atrophy is restricted to Corti's organ. The latter form of 
affection approaches the type of sacculocochlear degeneration (degener- 
ation of the pars inferior) in congenital deafness. In high degrees of 
cretinic dysacusis it is a typical occurrence to find the corner of the 
cochlear window filled with mucoid connective tissue or fatty tissue. 
This tissue embolus extends at one side to the tympanic mucosa and at 
the other side to the membrane of the cochlear window. Sometimes 
the corner of the vestibular window and the lumen of the stapes are 
also replete with mucous connective tissue. 

It is, of course, to be expected that in congenital deafness, repre- 
senting as it does the principal type of endemic constitutional deafness 
and dysacusis, the anatomical findings should vary considerably. In 
one of the cases of highly developed dysacusis which I observed, the 
capsule of the labyrinth contained pathological osseous foci of the type 
of osteitis vasculosa, such as is found in otosclerosis. There was also 
degenerative atrophy of the eighth nerve. In many cases the anatomical 
cause of deafness seems to be a more or less complete obliteration of the 
membranous labyrinth with aplasia of the nerve-end places and a stunted 
eighth nerve. 

I have found partial obliteration of the cochlear canal in a cretinic 
child with a high degree of partial deafness. The hair-cells of Corti's 
organ were completely absent, and the pillar cells partly so. 

Degeneration of the stria vesicularis seems to be a characteristic 
sign in nearly all cases of pronounced hardness of hearing and deafness 
in endemic cretinism. In one case there were epithelial duplicatures 
and septum formation of the membranous cochlear canal of the type 
of septum found in dancing mice, in the congenitally deaf and unde- 
veloped albino cats and dogs. 

The connective-tissue portions of the labyrinth are considerably 
atrophied in some cases; even the ligamentum spirale of the cochlea may 
be atrophied to such an extent that only a few fibre remnants remain. 
In the same cases, however, there is often considerable connective- 
tissue proliferation of the canalis spiralis, so that the atrophied spinal 
ganglion seems surrounded by a thick connective-tissue capsule. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 371 

One case has come under my observation in which there was con- 
siderable thickening of the membranous walls of the vestibule and 
especially of the external wall of the utriculus. 

In the cases of cretinic deafness which I had an opportunity of 
examining anatomically there were no pathological changes in the 
region of the auditory nuclei, in the central ramifications of that nerve, 
or in the cortex of the temporosphenoidal lobe. The peripheral, highly 
atrophied eighth nerve possesses perfectly normal nuclei in the cms 
cerebri and fibrous bundles running in a central direction. There is, 
however, still a possibility of auditory disorders being caused by changes 
of the central auditory nerve in isolated cases. 

Slight abnormalities of the concha, such as unusually large or small 
lobules, flat or kinked helix, Darwin's macacus point, deflected ear, 
asymmetric position of the concha, are fairly frequent in cretins, but 
I have not observed any gross malformations. The external auditory 
meatus was always normal. Nor have I found any exostoses. 

Symptoms. — The nasopharyngeal changes in cretinism lend them- 
selves to a division into three groups of symptoms. The first group 
deals with reduced hearing acuity, the second group with abnormal 
respiration, and the third group with abnormal articulation and lingual 
and mental insufficiency. 

The psychic behavior of cretins is important for the interpretation 
of the auditory disorders. The cretinic apathy, physical and psychic 
hebetude, may lead one to suspect considerable impairment of hearing 
which in reality does not exist. In the highest degrees of cretinism there 
may be no reaction whatever to a sound although the auditory apparatus 
may be perfectly in order. 

Subjective noises are only exceptionally complained of; the only 
cases I have observed referred to older cretins with but slight cretinic 
habitus, good intelligence, and slight catarrhal affections of the middle 
ear. There were only two cases of labyrinthine vertigo. In one of them 
there was deafness after cerebrospinal meningitis in a child; in the other 
there was medium hardness of hearing. 

The tympanic membrane presents more or less important catarrhal 
changes in most cases. It has a dull appearance, is discolored gray or 
reddish gray, and shows all degrees of retraction. Lime deposits in the 
tympanic membrane and accumulations of exudate in the middle ear 
are rare. I have not often met with suppurative inflammatory changes 
of the middle ear: there is nothing characteristic for cretinism in them, 
and they do not differ in any way from those in otherwise normal 
individuals. 

Functional Findings and Functional Tests. — In light degrees of cret- 
inism the functional tests do not differ in any way from those made in 



372 THE DISEASES OF CHILDREN 

normal children. Reliable results with the tuning-fork can, therefore, 
not be expected before the eighth or tenth year, especially if an exact 
and complete tuning-fork test is required. In the presence of important 
psychic disorders an exact functional test is impossible. We will then 
have to be satisfied with establishing the most important points (length 
of perception by bone-conduction, watch-ticking through the cranial 
bones, perception of c 4 -fork) in order to recognize any possible affection 
of the labyrinth. If there is only rudimentary reaction to acoustic 
impressions, the decision will be limited to the question as to whether 
or not there is any hearing ability. 

Greatly impaired intelligence in cretins with normal hearing may 
erroneously cause the impression of considerable partial or complete 
deafness. 

The aphonia of many cretins capable of hearing may be designated 
as aphasia or psychic deafness. These are not usually cases of pure 
cretinism, but combinations of cretinism and idiocy, and aphonia in 
these cases is not only caused by psychic impairment, but also by cerebral 
changes. 

Development of speech may be completely arrested owing to psychic 
insufficiency, or remain on a very low level in spite of good hearing 
ability. In cases of this kind the functional test may be a complete 
failure, as, owing to his hebetude, the cretin will fail to react to the 
loudest noises, in spite of good hearing ability. 

In most of these cases, however, the family, and especially the 
mother, will be able to impart useful information, stating, for instance, 
that the child would like to speak, but cannot. Continued observation 
will also conduce to a better understanding of their faculties. Thus, 
there may be noticed a motor reaction to the bark of a dog, the sound 
of a trumpet, rattle, etc., when the child believes himself unobserved. 

An important aid in deciding upon the hearing ability of cretins 
is their gait. Cretins who are very hard of hearing or totally deaf have 
a gliding, grating, groping gait. Walking with extended legs is found 
only in cases where the static labyrinth is out of function. I have ob- 
served spontaneous nystagmus in no more than five cases, in two of 
which there was degenerative affection of the labyrinth, while the others 
were highly nervous, restless cretins who, besides, suffered from epi- 
leptic convulsions. The hearing acuity for conversation and whispering 
can only be determined in cretins of fairly good intelligence. Unintelli- 
gent cretins, even with good hearing ability, will not repeat the test words 
at all or only indistinctly, or else they will give the same stereotyped 
answer to widely different test words. In making a functional test on 
cretins with inferior intelligence, no questions in regard to sounds or 
noises should be asked to which the answer is simply yes or no. Even 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 373 

intelligent cretins are easily susceptible to suggestion, and the less 
intelligent ones will mechanically reply "yes" to each question for a 
time and then resort to a stereotyped "no." 

The reflex excitability of the static labyrinth is perfectly normal in 
most cases. In some I have observed the reflex nystagmus produced 
after 10 rotations or by heat lasted for an unusually long time (30-40 
seconds, as against the normal time of 15-20 seconds). But since in 
these cases there was neither spontaneous nystagmus nor any symp- 
toms on the part of the static labyrinth, this increased reflex excitability 
cannot be regarded as pathological, but merely as a variety within normal 
limits. In some cases of cretinic deafness the reflex excitability of the 
static labyrinth was maintained; in others it was absent. 

Diagnosis. — In cretins who respond well to the tests an exact 
diagnosis of the otitic affection can be made; in those incapable of intel- 
ligent response it will be necessary to be content with an approximate 
determination of the degree of dysacusis, or even with a decision as to 
whether the cretin is deaf or not. In three cases of adult cretinic idiots 
I was unable even to determine the latter question. 

The characteristic hearing disorders of cretins may be clinically 
divided into three groups. The first group deals with catarrh of the 
middle ear, which in cretins is caused by hypertrophy of the lymph- 
adenoid tissue of the nasopharyngeal tract, especially adenoid vegetations, 
far more frequently than in normal individuals. The second group 
comprises those cases of cretinic deaf-mutism which, barring exceptions, 
belong to the type of endemic deafness and deaf-mutism. To this group 
belong cases of pure cretinism as well as combinations of cretinism and 
idiocy. The third group refers to cases of medium hearing ability in 
comparatively intelligent cretins, in whom an exact functional test 
reveals an affection of the internal ear. The anatomical findings will 
show a degenerative atrophy of the octavus and the nerve-end places 
of the labyrinth. 

It is a well-known fact that the psychic signs of cretinism sometimes 
appear in the wake of acute infectious diseases. It is not yet quite 
decided whether labyrinthine hardness of hearing of cretins is con- 
genital or a sequel of acute infectious diseases. I incline to the former 
view, because in normal children these affections occur very rarely, and 
then almost exclusively after typhoid fever. 

Moderate changes of the internal ear do not seem to be very rare 
in cretinism, but in view of the impaired intelligence the tuning-fork 
test is necessarily imperfect in most cases, rendering an exact localiza- 
tion of the otitic changes impossible. 

Treatment. — The treatment of cretins with thyroid substance has 
found an ardent advocate in v. Wagner, who, as far back as 1904, em- 



374 THE DISEASES OF CHILDREN 

phasized the importance of the question as to whether it would be 
possible to remove the lingual disturbance and particularly the under- 
lying hearing disturbance by thyroid treatment. This is really possible 
in a large number of cases. The thyroid tablets of Burroughs, Well- 
come & Co. are to be recommended for this purpose. Each tablet 
contains 0.324 Gm. of active thyroid substance. Von Wagner pre- 
scribes in most cases 1 tablet a day, which may be temporarily increased 
to 1} 2-2 tablets if indicated. In weak infants, where a dose of 1 tablet 
may lead to disorders, such as acceleration of the pulse, excitation, 
convulsions, acute emaciation, depression, and disturbed sleep, the dose 
should be reduced to x /i tablet a day, or the medication should be inter- 
rupted altogether for a time. 

The changes of the middle ear in catarrhal affections of that region 
depend upon the condition of the nasopharyngeal tract. Thyroid 
medication leads to a quantitative decrease of the lymphadenoid tissue 
and reduced swelling of the incrassated mucous membranes of the naso- 
pharynx. This is followed by an improvement and sometimes by a 
complete cure of the middle-ear catarrh, with the consequence that the 
hearing acuity is improved or becomes normal. 

The hearing disturbances of cretins which are caused by changes 
of the internal ear may sometimes be influenced by thyroid medication. 
There are several cretins among the cases I have observed whose dysa- 
cusis was definitely demonstrated and who experienced an improvement 
in their hearing acuity under the thyroid treatment instituted by v. 
Wagner. The duration of perception through the cranial bones had 
increased, c 4 was audible much longer, and the ticking of a watch which 
previously could not be heard was now perceived through the cranial 
bones. I have observed two of these cases for seven years, during which 
I found that the improvement set in comparatively rapidly, but after 
having reached a certain degree of perfection remained constant. The 
hearing acuity of these two cases has not changed for these five years, 
and in spite of thyroid treatment it has not been possible entirely to 
remove the changes of the internal ear. It is satisfactory to note, how- 
ever, that there has been no relapse and that the improvement once 
attained has remained constant. 

In cases of cretinic deafness administration of thyroidin offers no 
chance of success. Deaf cretins with good intelligence should be placed 
in an institute for the deaf-mute, otherwise in an asylum for imbeciles. 
V. Wagner is right in stating that the hebetude of cretinic deaf-mutes 
is usually so great that they are refused admittance by schools for the 
deaf-mute. 

In aphonia (psychic", cretinic aphasia) thyroidin treatment has in 
most cases given surprisingly good results, the intellect having been 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 375 

developed in many cases. As the latter increases, reaction to sound 
which was previously absent is incited, next follows development of 
speech, and after one or two years' treatment there is excellent hearing 
ability in cretins who before treatment seemed to be totally deaf. Un- 
fortunately, these improvements soon come to a halt, and it would be a 
mistake to regard these cases as cured. The physical and mental devel- 
opment of these children had been considerably retarded, and their 
hearing ability which was unquestionably present was unable to assert 
itself, owing to their high degree of intellectual insufficiency. If children 
of this description are placed in institutions for the imbecile, they are 
usually taken for deaf. It requires attentive observation to recognize 
whether a child is capable of hearing, and his mental development has 
been retarded to such an extent that the hearing ability cannot assert 
itself, so that there can be no question of lingual development. In some 
cases there is nothing but rudimentary articulation even after thyroid 
treatment, while others will remain mute. In the former cases, however, 
the improved hearing ability is demonstrable by functional tests, and it is 
certainly worth noting that even in these cases the excitability for 
sounds can be awakened or improved by thyroid treatment. 

Endemic deafness, likewise, is the object of successful treatment in 
cretinic degeneration. Von Wagner has instituted valuable attempts in 
this direction. In the district of Judenburg, Styria, where there are 
many families with positively cretinic children, he administered thyroid 
tablets to pregnant women and later to the new-born. 

III. AFFECTIONS OF THE EAR IN ACUTE INFECTIOUS DISEASES 

Acute infectious diseases in childhood endanger the hearing prop- 
erties to a great extent. The development of otitis media is favored by 
swelling of the mucous membrane in the nasopharyngeal tract, by con- 
tinuous passive dorsal decubitus, and by disturbed nasal respiration. 
The respiratory difficulties are particularly caused by voluminous accum- 
ulations of secretion in the nasopharyngeal tract and the inability of 
expectorating to a sufficient extent. This will cause irregular ventilation 
of the tympanic cavity after a short time. Subjective and objective 
signs of continued occlusion of the tube, such as sensation of fulness in 
the ear, heaviness in the head, moderate reduction of hearing acuity, 
are demonstrable in older children. Immigration of pathogenic germs 
from the nasopharyngeal tract into the tympanic cavity leads, directly 
or through catarrhal changes of the middle ear, to inflammatory and 
suppurative affections of the same. 

Both the labyrinth and the auditory nerve are endangered by many 
affections in the course of acute infectious diseases, such as suppurative 
labyrinthitis, panotitis, neurolabyrinthitis. 



376 THE DISEASES OF CHILDREN 

Prostration of the little patient and insufficient nursing bring on 
the danger of necrosis of the auricular cartilage. This may be spon- 
taneously produced by ischsemia in the condition of marasmus; other- 
wise it is due to kinking or wrong position of the concha while lying 
down on one side. The blood circulation in the concha, which in cases 
of great prostration is weak, will be entirely arrested through kinking, 
and necrosis, which will develop therefrom, can be recognized by the 
appearance of brownish-black spots. 

These considerations are the foundation for some very important 
hygienic rules concerning the ear. 

The ear should be carefully examined in all cases of acute infections 
of children, even if they do not complain of any otitic symptoms. Should 
the latter be present, otoscopic examination is particularly urgent if 
they can at all be referred to the ear in accordance with the symptoma- 
tology as described in previous chapters (decrease of hearing acuity, 
headache, vertigo, equilibrial disturbances, vomiting, etc.). 

In order to prevent infection of the middle ear from the nasopharyn- 
geal tract, instillations of a }^ per cent, solution of silver nitrate into 
the nose have been recommended by S. Weiss and }/% per cent, oily 
menthol solution by Gomperz. Disinfection of the oral cavity by rins- 
ing or the use of formamint tablets (3-5 daily) is of importance in all 
cases. 

Free respiration should be secured in seriously affected children, 
and care be taken by frequent changes of position that there be no 
accumulation of mucus in the nasopharyngeal space. Adrenalin plugs 
(sol. adren. 1.0, glycerin, aq. dest. aa 15.0) may be inserted into the 
nasal canals; this, and careful cleansing with cotton tips saturated with 
vaseline oil or a Yl P er cent, menthol vaseline solution, will keep the same 
permeable. Care should be taken to have the concha in the correct 
position in the lateral decubitus, and it is often advisable to support it 
by a small cotton-wool cushion. The external auditory meatus should 
be firmly plugged with cotton wool previous to applying ointments or 
liniments to the head, especially if they contain highly irritative medica- 
ments, or previous to douching the head or bathing. 

1. AFFECTIONS OF THE EAR IN SCARLET FEVER AND MEASLES 
Anatomy. — In typical cases of scarlatinal and morbillous otitis 
the affections consist almost exclusively in inflammations where the 
purulent disintegration has rapidly advanced to the deep parts and 
involved the bone in a short time. This explains why extensive involve- 
ment of the tympanic membrane, granulations in the tympanic cavity, 
and serious otitic changes of the auricular ossicles are found as early as 
one or two weeks after the onset of the inflammation. Suppurative 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 377 

resorption of the ligaments and mucosal folds may soon lead to exfoliation 
of the auricular ossicles. 

The histological picture is that of a violent inflammation and necrosis 
of the mucous membranes, and in grave cases has all the signs of diphthe- 
rial inflammation. Bacterial examination usually shows streptococci in 
pure culture, sometimes the bacillus diphtherise or mixed infections. 

The changes occurring in panotitis of the labyrinth correspond to 
hyperacute diffuse suppuration of the labyrinth. The nerve-endings 
are entirely destroyed in a short time, and in the further course of the 
suppuration the entire membranous labyrinth may likewise be destroyed. 
Empyema of the labyrinth, resulting from these conditions, may be 
cured spontaneously before the suppurative inflammation has spread 
to the surrounding bone. Should, however, the suppuration of the laby- 
rinth continue, the inflammatory process will spread to the osseous 
capsule. There will be all the anatomical signs of complicated diffuse 
suppuration of the labyrinth (see p. 270), and in some cases sequestra 
will be expelled. Attention may be called to the possibility of a compli- 
cating neuritis occurring in scarlatinal otitis. 

The anatomical changes in light cases of scarlatinal otitis or in acute 
catarrh of the middle ear do not differ from those of the non-scarlatinal 
form. The same refers to light cases of middle-ear affections occurring in 
the course of measles. 

Frequency and Occurrence. — The frequency of suppurative otitis 
media in scarlet fever and measles varies, according to the virulence of 
the prevailing epidemic, between 1 and 33 per cent., as has been statisti- 
cally demonstrated. The ear affections seldom occur before or during 
the exanthema; in most cases during the stage of desquamation. In 
measles they may occur as soon as the fever has run its course. When 
they occur at an early stage, otitis appears as an enanthematous part 
manifestation of scarlatina and measles. Light inflammatory changes of 
the middle ear are very frequent in measles. 

One of the most dangerous ear affections occurring in the course 
of scarlet fever and measles is panotitis. It occurs much more frequently 
in scarlatina than in measles, and consists in suppurative inflammation 
of the middle and internal ear. The middle ear and labyrinth are affected 
simultaneously, or otitis media is followed by suppuration of the internal 
ear. Panotitis, which usually attacks both auditory canals, occurs 
more frequently at the climax of scarlet fever than during the period 
of desquamation or convalescence. It is only exceptionally that both 
labyrinths are attacked simultaneously, although the interval may not 
amount to more than a few hours or days. In some measles cases pan- 
otitis will not appear before the suppuration of the middle ear has existed 
for several weeks. • 



378 THE DISEASES OF CHILDREN 

The danger of fulminating, grave inflammations of the ear and of 
subsequent panotitis is especially great in scarlatinal dipthheria and 
measles complicated by pneumonia. 

Symptoms. — The initial symptoms of scarlatinal and morbillous 
otitis are those of a severe acute inflammation of the middle ear, con- 
sisting in severe headache, considerable dysacusis setting in without 
any warning, high fever, insomnia, and unrest. 

Otoscopic examination (see Fig. 83, 1-5) in the first stages of the 
inflammation reveals pronounced swelling, bulging, and deep reddening 
of the tympanic membrane. The swelling is often flesh-like, and the 
membrane has completely lost its membranous character. Purulent 
disintegration soon follows. Perforation may occur as early as a few 
hours after onset of the inflammatory manifestations, and the rapidly 
spreading suppurative disintegration of tissue often causes large defects 
of the tympanic membrane inside of a few hours. In spite of careful 
treatment the secretion will become rapidly fetid, owing to repeated 
retention or to spreading of. the inflammation to the bone. After the 
suppuration has lasted a few weeks, there will be abundant granula- 
tions in the middle ear, and the secretion is mixed with blood from the 
granulations which are very vulnerable. 

The labyrinth symptoms usually set in after perforation of the 
tympanic membrane, and only exceptionally in the early stages of the 
otitis. They consist in sudden and considerable impairment of hearing, 
or deafness, violent labyrinth vertigo, with spontaneous nystagmus, 
equilibrial disturbances, and vomiting. 

Diagnosis. — Taking the above symptoms into consideration, there 
will be no difficulty in making a diagnosis of otitis media or panotitis. 
Timely otoscopic examination is of the greatest importance, so that the 
initial stages of the inflammation may not be overlooked. Accordingly, 
this is indicated in all cases of scarlatina and measles, even in the ab- 
sence of any special otitic symptoms. Another point of importance is 
to continue taking the temperature regularly in acute infectious diseases, 
even after the fever has run its course. This will guard against over- 
looking the initial stages of a late otitis in infants or debilitated children. 

There is no doubt that in a considerable number of cases the develop- 
ment of suppurative otitis and the spreading of the purulent inflamma- 
tion to the endocranium or labyrinth is favored by the fact that the 
initial stages of scarlatinal otitis have been overlooked or have not been 
treated with the necessary care and energy. 

Course and Prognosis. — Scarlatinal and morbillous otitis are 
rightly dreaded on account of the violence of the subjective and objec- 
tive pathological manifestations, the rapid disintegration of tissue, the 
frequency of permanent changes of the middle ear, and the danger of 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 379 

early spreading to the mastoid. In old neglected cases there is the 
danger of pus descending toward the submaxillary bone, with inflam- 
mation of the articulation and subsequent ankylosis. 

The prognosis is not unfavorable, provided correct treatment is insti- 
tuted at the right time. Cures have often been effected under conserva- 
tive treatment, but permanent changes of the tympanic membrane and the 
middle-ear spaces (cicatrization, adhesions, synechise, persistent perfora- 
tions), with consequent hearing disturbances which are usually of a me- 
dium degree and permanent, will occur more frequently than in true otitis 
media. Otitis developing in the course of measles practically resembles 
scarlatinal otitis, but, as a rule, does not run so severe a course. 

Scarlatinal and morbillous otitis tends to chronicity, nearly 25 per 
cent, of all chronic otorrhoeas being traceable to the chronic degenera- 
tion of the former. It is for this, if for no other reason, that early and 
energetic treatment of middle-ear suppuration is indicated. 

The course of panotitis is unfavorable in nearly all cases. Unless 
the first attack of labyrinthitis has led to complete destruction of the 
hearing ability, total deafness will usually set in a few hours or days 
afterward. Permanent circumscribed suppuration of the labyrinth is 
very rare in panotitis. 

When recovery has taken place, there will be complete deafness in 
most cases. Some parts of the coehlea may be spared and some hearing 
remnants consequently preserved. Such remnants may continue to 
persist, but they may also gradually diminish and end in deafness, 
owing to secondary atrophy of Corti's organ and the cochlear nerve. 
Deafness will then persist and soon lead to deaf-mutism in young chil- 
dren. There is less danger of the labyrinth suppuration spreading to 
the endocranium. Death from purulent meningitis due to scarlatinal 
panotitis occurs very rarely. 

Treatment. — The principal point to be observed is to institute 
early and effective drainage of the inflammatory focus of the middle 
ear. Fatal spreading of the process can be best prevented by early 
paracentesis and attentive treatment, care being taken that there is 
always free evacuation of the secretion. In the further undisturbed 
course, the treatment of scarlatinal and morbillous otitis does not differ 
from that of the ordinary forms (see p. 156). The same refers to the 
indications for operative interference if in the course of the affection 
the mastoid should become involved, or there be signs of any extra- or 
endocranial complication. In labyrinth manifestations with consequent 
danger of retention or stagnation of pus in the middle ear, antrotomy is 
indicated, even if there be no clinical mastoid symptoms. Operation 
may become necessary at a later stage when the middle-ear suppuration 
has become chronic and exhibits surgical symptoms (see p. 202). 



380 THE DISEASES OF CHILDREN 

In panotitis an operation on the labyrinth can only exceptionally 
be considered in cases where there is danger of the suppuration spread- 
ing to the endocranium, thus indicating the presence of a complicated 
labyrinth suppuration (see p. 270). The details of conservative, symp- 
tomatic treatment are described in the chapter on Suppuration of the 
Labyrinth (p. 265). 

2. AFFECTIONS OF THE EAR IN DIPHTHERIA 

Etiology. Occurrence. — Diphtheritic inflammation of the external 
auditory canal does not occur often. It may have been conveyed there 
from a similar affection of the middle ear, but may also occur with a 
healthy state of the middle ear. Diphtheritic inflammations of the ex- 
ternal auditory canal are usually deep-seated in the anatomical sense, 
caused by pyocyaneus infection or severe acute or chronic streptococcus 
infection of the middle ear. 

Otitis media occurs less often in the florid stage of diphtheria, more 
frequently after the acute manifestations and the fever have run their 
course. 

True diphtheria is usually caused by simple spreading of the inflam- 
matory process from the nasopharyngeal space to the ear, and only 
exceptionally by purely diphtheritic infection by way of the tube. 
Primary diphtheritic infection was first observed by Burckhardt- 
Merian. 

Symptoms and Course. — It is a noteworthy fact that in infants and 
young children otitis media occurring in the course of diphtheria may 
work serious destruction in the tympanic cavity without perforating 
the tympanic membrane. Genuine diphtheritic membranes are often 
formed in the middle ear. Extensive necrosis of the osseous parts of 
the auditory canal (auricular ossicles, mastoid process, temporal bone, 
and labyrinth) and endocranial complications may develop in grave 
cases. Spreading of the suppurative inflammation to the labyrinth will 
cause total deafness and produce all the other symptoms of panotitis. 

Otherwise there is no characteristic difference between "the diph- 
theritic and the genuine forms of otitis media. 

The diagnosis is not difficult when the picture of otitis media is 
fully developed and there is diphtheritic inflammation of the external 
auditory duct. The difficulty is greater when the inflammatory mani- 
festations of the tympanic membrane are but slightly developed and the 
inflammatory process extends toward the deeper parts. However, careful 
and repeated otoscopic examination, functional tests, and regular con- 
trol of the temperature will lead to the correct diagnosis. The latter 
should be continued in all cases of diphtheria, as in scarlatina and measles, 
even after the fever has run its course. Should there be a fresh acces- 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 381 

sion of temperature, the possibility of an inflammatory process of the 
middle ear should be considered, even in the absence of any particular 
otitic symptom. 

Bacterial examination will decide the question whether the otitis 
media has been caused by the diphtheria bacillus or by other bacteria, 
most frequently by streptococcus in the post-diphtheritic stages. This 
examination is best carried out with the secretion obtained by 
paracentesis. 

Treatment. — Injection of serum is the principal treatment aside 
from the methods of treatment described in previous chapters. Instil- 
lation of lime water has a beneficial effect in cases of diphtheritic inflam- 
mation of the auditory canal with formation of membranes. If the 
external auditory canal is involved, as well as in cases of noma, the 
inflammation can often not be prevented from terminating in a high 
degree of stenosis or atresia of the auditory meatus, even with careful 
local treatment. 

The prognosis is not unfavorable, provided the local and general 
treatment have been instituted in time. Ever since the introduction of 
serum treatment the frequency of suppurative otitis media seems to have 
diminished and the course of the affection to have become milder. The 
danger of panotitis is considerably less in diphtheria than in scarlatina. 

3. AFFECTIONS OF THE EAR IN EPIDEMIC PAROTITIS (MUMPS) 

Anatomy. Occurrence. — In epidemic parotitis a complication with 
neurolabyrinthitis is to be feared. The inflammation may be confined 
to the vestibular or cochlear part of the labyrinth and eighth nerve, but 
in some cases it attacks the entire eighth and may even spread to the 
facial nerve, so that the entire nerve bundle of the internal auditory 
canal will be involved. 

It may be assumed that in some of the cases there are acute inflam- 
matory changes of the serous type which are capable of involution. 
In other cases there is an infectious inflammation which impairs or 
destroys the physiological function of the internal ear, either directly 
or owing to secondary degenerative processes of the labyrinth or eighth 
nerve. The affection is usually unilateral. 

The otoscopic examination shows that the tympanic membrane is 
either normal or but slightly changed. The middle ear is intact except 
for moderate catarrhal changes. The labyrinth manifestations corre- 
spond to the symptom-complex of serous labyrinthitis (p. 264) or cir- 
cumscribed suppuration of the labyrinth (see p. 265), and only excep- 
tionally to that of diffuse suppuration of the labyrinth. 

Course and Prognosis. — The course of otitic affections in parotitis 
varies greatly. In a large number of cases there may be a complete 



382 THE DISEASES OF CHILDREN 

cure, with restoration of the physiological function of the labyrinth, 
even where the hearing ability had been considerably reduced or elimi- 
nated at the climax of the inflammation. These are the cases in which 
parotid labyrinthitis occurs and continues under the picture of serous 
labyrinthitis. The static labyrinth completely regains its reflex excit- 
ability in many cases. Even where the inflammation had involved the 
entire labyrinth and permanent deafness had set in, owing to circum- 
scribed suppuration of the cochlea, cures have been observed with 
perfect functional restoration of the static labyrinth. 

Mauthner, a member of my department, communicated a case in 
which the history showed that parotid labyrinthitis (bilateral in this 
case) had originally attacked the acoustic and static labyrinths, there 
having been deafness, vertigo, equilibrial disturbances, and vomiting. 
The patient was examined one year after the cure of parotitis, showing 
deafness of the right ear, but perfectly normal reflex excitability of the 
right static labyrinth. 

Many cases of parotid labyrinthitis are cured with permanent 
hardness of hearing. It may also be assumed that diminished excit- 
ability of the static labyrinth may persist. The paralysis of the facial 
nerve is usually completely cured. 

The treatment is purely symptomatic, consisting in rest in bed and 
application of ice-bags to the head. In violent paroxysms of vertigo the 
room should be darkened, and galvanization of the auditory nerve 
instituted to produce galvanic nystagmus in the opposite direction to 
the pathological nystagmus. In cases of persistent, protracted vertigo, 
narcotic remedies should be considered, either internally or subcutan- 
eously. Rest in bed should, of course, be continued until the nystagmus 
is under control, even after cessation of the vertigo attacks. After 
parotitis and the irritative manifestations have run their course, treat- 
ment should consist in application of hot air, sudorific measures, and 
galvanization of the eighth nerve. The latter treatment should be 
continued for several weeks two or three times a week, with the anode 
to the ear and a current of 4-6 ma., each application to last from five 
to ten minutes. I have not seen any results following the injection of 
pilocarpine or fibrolysin. 

4. EAR AFFECTIONS IN TYPHOID FEVER 

Anatomy. Occurrence. Course. — Catarrhal affections of the middle 
ear are of frequent occurrence in the course of typhoid fever. They are 
usually exudative with accumulation of a yellow mucous secretion. 
The affection is often combined with an affection of the labyrinth. 

Suppurative otitis media with an inflammatory course is but rarely 
observed in typhoid fever. In these cases suppurative disintegration 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 383 

of the tympanic membrane occurs at a rapid rate, and there is also the 
danger of the inflammation spreading early to the bone. Furthermore, 
these cases are threatened with panotitis, which means extension of the 
suppurative otitis media to the labyrinth and endocranial complications. 

As was mentioned above, the labyrinth affections occurring in the 
course of typhoid correspond to the type of serous labyrinthitis. Cir- 
cumscribed or diffuse suppuration of the labyrinth is rarer. Like the 
rest of typhoid otitic affections, labyrinthitis is more frequently observed 
unilaterally than bilaterally. 

The anatomical changes of the internal ear seem to have an elective 
preference for the eighth nerve. It is a question whether there are exu- 
dative and inflammatory processes going on in the acute stage, as is the 
case in typhoid middle-ear affections. 

Investigations made by Manasse and Sporleder have shown that 
typhoid deafness is due to an inflammatory process of the auditory 
nerve or within the labyrinth. In one case of typhoid deafness Manasse 
demonstrated chronic inflammatory changes of the membranous laby- 
rinth, consisting in new-formation of connective tissue, degenerative 
atrophy of the neuro-epithelium and the nerve ganglia, and in changes 
of the osseous capsule of the labyrinth (pathological osseous foci). 

Hartmann has called attention to the frequency of otitic affections, 
notably of catarrh and suppurative inflammation of the middle ear, in 
exanthematous typhoid. In the latter affection the typhoid exanthema 
occurs exceptionally at the concha or external auditory meatus, and is 
usually associated with hemorrhagic vesiculation of the external auditory 
meatus or tympanic membrane. 

Otoscopic Findings and Symptoms. — In cases of exudative catarrh 
of the middle ear the tympanic membrane is saturated with a yellow 
secretion (Plate VIII), the line of the manubrium is narrow, and the 
tympanic membrane is either normal or moderately retracted. If only 
part of the middle-ear spaces is filled with exudate, the characteristic 
level line (Politzer) can be observed. Fulminating hemorrhagic inflam- 
mation of the middle ear which occurs in the course of typhoid is 
characterized, like influenza otitis, by the formation of vesicles contain- 
ing a serous, hemorrhagic, or purulent fluid in the external auditory 
meatus and tympanic membrane, which is followed later by evacuation 
of hemorrhagic pus. 

In uncomplicated cases the functional test shows a reduction of the 
hearing acuity and all the signs of obstructed sound-conduction. 

The labyrinth symptoms consist in hardness of hearing, subjective 
noises, paroxysms of vertigo, and equilibrial disturbances. The nervous 
character of the subjective noises can be definitely established in these 
cases by means of the galvanic current. If the anode is applied to the 



384 THE DISEASES OF CHILDREN 

ear (tragus or mastoid) and the cathode at an indifferent place, the sub- 
jective noises will be considerably reduced on closing the current, or 
they may entirely disappear while the current passes through the body. 
When the cathode is applied to the ear after the current has been 
reversed, there will be an increase of the subjective noises on closing the 
current. The intensity of the paroxysms of vertigo and equilibrial dis- 
turbances is slight, there being rather a continuous sensation of vertigo 
without any distinct character of rotation, unstability, etc. 

Treatment. — The catarrhal or inflammatory changes of the nose 
and nasopharyngeal space claim first consideration. If there is spon- 
taneous improvement of the hearing acuity within a few days, indicating 
resorption of the exudate, no local treatment whatever is needed. Should 
the accumulation of secretion in the middle ear continue, air may be 
inflated into the nose after the inflammatory process is over. If, in 
spite of this treatment, the exudate is not arrested, it should be evacu- 
ated by paracentesis (see p. 151). 

The treatment of acute typhoid otitis is described on p. 165. 

When the labyrinth is affected, the disagreeable tinnitus and the 
sensation of vertigo may be reduced or temporarily arrested. Correct 
lateral position of the patient, opposite to the direction of the nystagmus, 
is a favorable measure. In the presence of nausea, the administration 
of food requires the greatest care, and none but cool and liquid food 
should be given in small quantities at a time. 

There should be no local treatment in typhoid affections of the 
labyrinth and eighth nerve. It is questionable whether drainage of 
the cochlea can be effected and total deafness prevented, in cases of 
diffuse suppuration of the labyrinth, by opening the lateral semicircular 
canal and early incision of the pus focus in the static part of the labyrinth. 

Prognosis. — The exudative middle-ear catarrhs in typhoid fever are 
prognostically favorable. Hearing acuity usually returns to normal, but 
in some cases a moderate degree of dysacusis remains. 

Suppurative typhoid otitis does not greatly differ prognostically 
from morbillous otitis. As in the latter, the danger of panotitis is smaller 
than in scarlet fever. 

It cannot be denied that typhoid otitis has a tendency to chronic- 
ity, — a reason why there should be careful treatment in the initial 
stages of the inflammation. Neglect of these dangerous ulcerations is 
attendee! with evil consequences. 

Serous labyrinthitis occurring in the course of typhoid may be 
cured with complete restoration of the labyrinthal function; in circum- 
scribed suppuration of the labyrinth a considerable reduction of the 
hearing acuity will persist, and diffuse suppuration of the labyrinth will 
lead to deafness and later to deaf-mutism. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 385 



5. EAR AFFECTIONS IN THE COURSE OF INFLUENZA (LA GRIPPE) 

Anatomy and Occurrence. — Frequency and intensity of ear affec- 
tions in influenza vary and may attain a very high degree of virulence 
in epidemics. The lightest cases, which are of very frequent occur- 
rence, are characterized by transition from simple catarrh to inflam- 
mation. Myringitis hsemorrhagica and acute exudative catarrh of the 
middle ear are not of rare occurrence. 

Otitis hsemorrhagica, or briefly designated as influenza otitis, is 
caused either by the influenza bacillus alone or by a mixed infection 
(influenza bacillus, streptococcus pyogenes, streptococcus mucosus). 
Anatomically, influenza otitis is characterized by hemorrhagic exu- 
dates into the middle-ear spaces, with abundant secretion of fibrin. 
The inflammation often spreads to the mastoid in a remarkably 
short time. Simultaneous involvement of the labyrinth (panotitis) is 
very rare in influenza otitis. Among the endocranial complications, 
otogenic influenza meningitis is most dreaded, as it usually runs a hyper- 
acute, fatal course. 

Infectious neuritis of the eighth nerve, often combined with neu- 
ritis of the trigeminus, abducens, or facial nerves, may occur in the course 
of influenza, and pronounced nerve hearing disorders after influenza 
(neurolabyrinthitis) have been reported by various authors. 

Symptoms. — In simple catarrh or light inflammation of the middle 
ear, the tympanic membrane is grayish red, with radial vascular injec- 
tion and no bulging. Hearing acuity is moderately reduced, the temper- 
ature is normal, and the pains are unimportant. In influenza myrin- 
gitis, blood vesicles will occur in the external auditory canal and tympanic 
membrane. The external wall of the blood-vessels consists of the epider- 
mal epithelium of the skin or the epidermal layer of the tympanic mem- 
brane. The latter may be completely hidden by blood vesicles. In 
other cases punctiform hemorrhages will occur in the external auditory 
canal and tympanic membrane. 

The onset of typical influenza otitis is characterized by sudden 
intense earache, considerable dysacusis (3^2-6^ feet C), and high fever. 

The otoscopic findings in typical influenza otitis are characterized 
by blood vesicles in the external auditory canal and tympanic membrane. 
In the further course of the affection there will be accumulation of a 
sero-hemorrhagic, and later purulent hemorrhagic, exudate in the tym- 
panic cavity, and finally suppurative decomposition and perforation of 
the tympanic membrane unless an outlet has been provided for the pus 
by paracentesis. 

The functional test shows severe obstruction to sound-conduction 
in uncomplicated cases. 
VI— 25 



386 THE DISEASES OF CHILDREN 

After the pus secretion from the external auditory meatus has once 
commenced, the symptoms of uncomplicated cases do not differ from 
those of true acute suppuration of the middle ear (see p. 152). 

When the labyrinth has become involved, there will be the typical 
symptom -complex of reduced upper sound-limit, hardness of hearing, 
spontaneous nystagmus, rotatory vertigo, equilibrial disturbances, and, 
in very high degrees of development, total deafness and vomiting. 

The catarrhal affections as well as myringitis hsemorrhagica admit 
of a thoroughly favorable prognosis. In the latter affection the vesicles 
are usually emptied spontaneously after a short existence, the contents 
of the small vessels being gradually resorbed. Traces of tympanic 
hemorrhages may remain visible at the tympanic membrane for a long 
time in the shape of dark red-brown spots. In the end there is complete 
resorption of the coagula. Pigmentation of the tympanic membrane 
after hemorrhages is one of the greatest rarities. 

Influenza otitis has a tendency to spread to the epitympanum and 
antrum. Owing to the rapid extension of the inflammation an empy- 
ema of the mastoid may develop in a short time. Retention of the secre- 
tion in the tympanic cavity will increase the danger of the inflammation 
spreading to the mastoid, especially to pneumatic ones, where large 
abscesses will rapidly develop through purulent disintegration of the 
osseous septa. The external cortical layer will be perforated and a 
subperiosteal mastoid abscess will be the result. When the medial 
cortical layer has been perforated, the consequence may be a perisinous 
abscess. 

The treatment of otitis has been discussed in the corresponding 
chapters on pp. 138, 150, 156. It should be most particularly empha- 
sized that in influenza otitis nothing but timely energetic measures 
can promote an uncomplicated favorable course and the prevention of 
complications. It is advisable not to wait for spontaneous perforation, 
but to effect an early relief of the middle-ear spaces by paracentesis. 
The principal task of the further treatment consists in maintaining a 
free outlet of the purulent secretion of the middle ear during the entire 
period of inflammation. 

6. MENINGITIC (MENINGOGENIC) LABYRINTHITIS (MENINGIC DEAFNESS) 

Anatomy and Occurrence. — Cerebrospinal meningitis involves con- 
siderable danger to the labyrinth. 

The meningitic purulent exudate penetrates into the internal audi- 
tory canal, and the suppurative inflammation spreads to the interior of 
the labyrinth over the dural lining of the internal auditory canal and 
alongside the nerve canals, or by way of metastasis. The result is sup- 
purative peri- and endolabyrinthitis with total destruction of all laby- 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 387 

rinthal nerve terminations. Histological examination has shown that 
in the early stages of purulent labyrinthitis the entire neuro-epithelium 
is destroyed within a few hours. A cure takes place under formation of 
cicatricial connective-tissue layers in the labyrinth. In some cases 
there will be obliteration of the labyrinth by connective-tissue forma- 
tion, which may be followed by osseous obliteration of the labyrinth 
spaces. Meningitic suppuration of the labyrinth corresponds almost 
without exception to the diffuse type. Functionally efficient places of 
the neuro-epithelium, especially in the region of Corti's organ, with 
clinically demonstrable hearing remnants, are practically never pre- 
served. 

Meningitic labyrinthitis usually sets in at the climax of cerebro- 
spinal meningitis at a time when the attention of the family is deflected 
from the otitic complaints by the grave general symptoms and the 
onset of deafness is hidden by the disturbed consciousness of the patient. 
This explains why meningitic labyrinthitis often remains unrecognized 
until the meningitis has run its course, and the affection of the ear remains 
unnoticed until at the time of convalescence the condition of deafness 
becomes apparent. 

The causative factor in a large number of cases of acquired deafness 
is meningitic suppuration of the labyrinth. The affection attacks almost 
without exception both labyrinths, either simultaneously or with a 
short intermission. The middle ear either remains perfectly intact or 
undergoes only catarrhal or light inflammatory changes. Meningitic 
panotitis of the scarlet fever or measles type is extremely rare. 

The otitic findings show the tympanic membrane to be either normal 
or but slightly changed by catarrh or acute inflammation; sometimes 
there is vascular injection along the insertion of the membrane. 

The onset of diffuse labyrinthitis is characterized by sudden deaf- 
ness. There are also violent paroxysms of vertigo, equilibrial disturb- 
ances, and vomiting if at first but one labyrinth had been attacked. If 
the suppuration attacks both labyrinths simultaneously, putting them 
out of action by inflammation, there will be but one paroxysm of ver- 
tigo or none at all. The grave general meningitic symptoms may veil 
the vertigo and its psychic sequelae, and the spontaneous nystagmus 
of the labyrinth may be counteracted by the central nystagmus of the 
meningitis. 

Treatment, Course, and Prognosis. — Treatment is powerless in 
meningitic labyrinthitis, which in the majority of cases will terminate 
in total and permanent deafness and later deaf-mutism in young chil- 
dren. Older children, who have been able to speak before the affection 
and acquired deafness after cerebrospinal meningitis, should be instructed 
in lip-reading at the earliest possible time, as this will prevent the devel- 



388 THE DISEASES OF CHILDREN 

opment of dumbness. Hearing remnants persisting immediately after 
meningitis will be preserved quantitatively unchanged in most cases; in 
others they will gradually decline and finally disappear. Only the 
future will show whether it will be possible to prevent the occurrence of 
total deafness, or at least to preserve some hearing remnants, by early 
operation on the labyrinth far away from the cochlea, perhaps at the 
eminence of the external semicircular canal. 

If labyrinthitis takes a more chronic course, it is possible for the 
suppurative inflammation to spread first to the capsule of the labyrinth 
and then, after fistulous perforation, to the middle ear. In this process 
the labyrinthal fistulse occur with great frequency in the region of the 
windows of the labyrinth and the promontory. 

7. AFFECTIONS OF THE EAR IN THE OTHER ACUTE INFECTIOUS DISEASES 

Affections of the ear in variola are relatively rare. According to 
Spira they are usually light and occur only in the grave forms of this 
affection (catarrh and light inflammations of the middle ear). 

In rubeola or infectious or varioloid erythema the eruption may 
spread to the concha and the external auditory meatus. 

In rubeola the retro-auricular lymph-glands are nearly always 
swollen. 

In erysipelas the exanthema may spread to the auricular region 
and the concha, simulating mastoiditis (see p. 179), while in rare cases 
acute serous labyrinthitis may develop. Cure takes place with restora- 
tion of the normal hearing acuity or slight reduction of the same. 

In pertussis the ear is not often involved. Acute myringitis or otitis 
which may develop in the course of violent paroxysms of coughing have 
also been observed; they do not differ in their course from the true form. 
Punctiform hemorrhages of external auditory meatus or tympanic 
membrane may occur exceptionally. 

Rupture of the tympanic membrane may occur in paroxysmal 
coughing if there was previous atrophy or lowered resistance from 
cicatrization. The violence of the cough may fling the secretion of the 
nose and nasopharyngeal tract through the tube into the middle ear, 
causing infection. In a similar way, acute otitis may occur in the course 
of catarrhal or croupous pneumonia. 

In dysentery of nurslings, myringitis, catarrh of the middle ear, 
or hemorrhagic otitis is of extremely frequent occurrence (see p. 161). 
A parotid abscess developing in the course of dysentery may exception- 
ally perforate into the external auditory canal. 

Light or medium otitic disturbances may occur at the climax of 
acute articular rheumatism. Examination will reveal the presence of 
neurolabyrinthitis. Graver forms of the latter affection, resulting in 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 389 

permanent dysacusis or deafness, occur only exceptionally in the course 
of acute articular rheumatism. The use of salicylic preparations in the 
latter affection may lead to intoxication of the labyrinth and eighth 
nerve. Examinations by Witmaack and Blau have shown that sali- 
cylic acid as well as quinine and antipyrin has an elective preference for 
the peripheral auditory ganglion as a point of attack. Otitis media 
occurring in the course of acute articular rheumatism does not differ 
from the genuine form of that affection. 

Osteomyelitis may exceptionally spread to the temporal bone or 
middle ear, either by direct continuity or by metastasis. 

IV. EAR AFFECTIONS IN CHRONIC INFECTIOUS DISEASES 
A. TUBERCULOUS DISEASES OF THE EAR 

Etiology (Mode of Infection). — The tuberculous diseases of the ear 
are caused by Koch's tubercle bacillus. The infection takes place by 
way of the blood or lymph tracts, or exceptionally direct by exposed 
traumas of the auricular region. The middle ear may also be infected 
through the tube, especially in cases where the tuberculous virus is 
present in the nasopharynx, in the oral cavity, or in the larynx. 

Otitic tuberculosis is in most cases a secondary affection, the num- 
ber of primary infections being comparatively small. As to the localiz- 
ation of the latter, the lobule of the ear may be especially mentioned, 
as well as tuberculous perichondritis, which is of frequent occurrence 
in childhood, but is often mistaken for other affections. 

Many of the cases reported in the literature as primary tuberculosis 
of the ear are unquestionably secondary, as the clinical demonstration 
of the primary focus, notably of the lymph-glands and intestines, did not 
succeed. Brieger and Goercke have pointed out the polymorphous 
character of the clinical picture of otitic tuberculosis, the cause of which 
they see in the pathogenic variety of tuberculous ear affections. Tuber- 
culous affections of the middle ear may develop by direct spreading of a 
tuberculous affection of the nasopharyngeal mucosa by way of the tube 
or by the formation of isolated tuberculous foci in the middle-ear mucosa. 
The osseous parts of the middle ear may be infected by tuberculosis 
simultaneously with the mucous membrane, or the chronic tuberculous 
suppuration may only spread to the bone after having persisted for 
some time, the result being tuberculous caries. The tuberculous sup- 
puration of the bone is at times circumscribed and limited to the auricular 
vessels, the attic wall, and antrum, but not infrequently extends over 
the entire temporal bone. Tuberculous softening foci develop at the 
upper wall of the upper auditory canal in a few cases, also at the root 
of the zygomatic process and the squama of the temporal bone: and 
these cases present the picture of osteoperiostitis from the first. 



390 THE DISEASES OF CHILDREN 

1 . Lupus of the Concha. Tuberculosis of the Lobule 

Lupus vulgaris appears at the concha in the same forms as at any 
other parts of the body. The clinical pictures vary, but their character- 
istic points consist in the presence of brown-red or brownish lupus 
nodules the size of a pin-head to a hemp-seed, which are embedded in 
the skin and do not change on pressure. 

Lupus seldom occurs at the concha alone and is much more frequently 
a part manifestation of a lupous affection of the facial skin. The affected 
part of the concha is diffusely infiltrated, and the lobule, for which lupus 
has a predilection, assumes an unshapely, thickened form. 

Fig. 121. 





Tuberculosis of the lobule of the ear in a child five years old. 

Lupus develops at the concha under the same picture as at any other 
part of the body), namely, as lupus maculosus, exfoliativus, tuberosus, 
exulcerans, crustosus, erythematodes. 

The diagnosis presents no difficulties in typical cases, but combi- 
nations of the various forms of lupus may produce polymorphous patho- 
logical pictures which are difficult to recognize. 

The object of the treatment is to destroy the lupous tissue by apply- 
ing the caustic stick, chlorate of zinc, the sharp spoon, the Paquelin 
cautery, or excision. In extensive ulcerations concentrated lactic acid 
may be tried. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 391 

Treatment with Finsen light has been followed by good results; 
radiotherapy has been equally recommended. Veiel advises applica- 
tion of pyrogallol ointment (0.2-2 per cent.) after cauterization, which 
is said to conduce to. elegant cicatrization. 

As a matter of course, general treatment (nourishing diet, etc.) 
should be strictly attended to, aside from applying local remedies. 

Hot-air treatment, after Hollaender, sometimes has a favorable 
effect. Dreuw's treatment consists in freezing lupus with ethyl chloride, 
followed by careful cauterization with crude hydrochloric acid. The 
following have also been recommended: Unguentum viride (Unna), 
creosote-salicylic plaster and pyrogallol plaster. Zinc-ichthyol ointment 
is applied in inflammatory irritation; Unna's tuberculin soap for 
softening lupous fibroma. Where disfiguring rigid scars are in prog- 

Fig. 122. 




Pre-auricular and auricular skin tuberculosis in a six-month-old child. 

ress of formation, thiosinamine or fibrolysin should be used, as they have 
occasionally led to very satisfactory cosmetic results (fibrolysin injec- 
tions, thiosinamine ointment soap, or thiosinamine plaster). Tuber- 
culosis preferably attacks the lobule (Fig. 121), whence it may become 
diffuse (Fig. 122). 

In these cases tuberculosis seems to be occasioned by a local infec- 
tion that has occurred by inoculation with tuberculous virus. The 
principal cause seems to be the puncture of the lobule for ear-rings, 
since recurring eczema or other irritations of the little canal may cause 
conditions favoring local infection. Haug found tubercle bacilli and 
a caseated tuberculous nodule in angioma of the lobule which had existed 
for 22 years. 

Tuberculosis of the concha develops very slowly with late ulceration. 



392 



THE DISEASES OF CHILDREN 



Fig. 123. 



The neighboring glands are usually involved. The prognosis is by 
no means unfavorable, as the course of the process is usually benign. 

2. Tuberculous Perichondritis 

Tuberculous inflammation of the cartilaginous integument is a 
rather rare affection. It occurs more frequently in young people than 
in the old. In most cases there seems to be a local tuberculous inflam- 
mation in otherwise healthy individuals. 

Symptoms. — Tuberculous perichondritis usually sets in under the 
picture of painless furunculosis of the external auditory meatus, less 
often under manifestations of phlegmonous perichondritis. Character- 
istic symptoms are the painless and afebrile, protracted course, livid 

discoloration of the skin, gradual ex- 
tension of the infiltration, and per- 
haps abscess formation at the base of 
the concha (descending tuberculous 
abscess). A fistula is usually formed 
spontaneously at the medial surface 
of the concha at the fusion of the 
auricular cartilage with the concha. 
Sometimes the pus perforates through 
one of the congenital osseous fissures 
or near the lobulus. 

Treatment. — Treatment with the 
Finsen light is useful in cases where 
no abscess has yet been formed. In 
the presence of fluctuation or of a fis- 
tula, surgical measures have to be in- 
stituted under anaesthesia. The abscess region is exposed by an incision 
of the concha, curetted with the sharp spoon, and tamponaded with Yi 
per cent, formalin gauze. Lactic acid has also proved very serviceable in 
cauterization of tuberculous granulations. 

After the cure a permanent deformity of the cymba concha? and the 
posterior line of insertion will nearly always remain. 




P Fc Pm 

Tuberculosis of the temporal bone in a child of 
five years. Carious destruction of the squama 
(Sgu), the zygomatic process, and the mastoid 
(Pm). Fe, fenestra vestibuli; Fc, fenestra coch- 
leae; P, promontory. 



3. Tuberculous Otitis Externa 

This otitic affection which sometimes occurs in childhood is wrongly 
named, since there is no question of a tuberculous affection of the seba- 
ceous glands, but always of tuberculous perichondritis of the auricular 
cartilage. The inflammation sets in under the picture of an auricular 
furuncle, but painless. The course likewise is painless. At first the 
infiltration may remain almost unchanged for several weeks; finally, 
however, the swelling will extend to the cavity of the concha, and sooner 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 393 

or later there will be fistulous perforation to the base of the ear, a fistula 
developing at the lower end of the line of insertion of the concha with 
all the characteristic symptoms of tuberculous fistulse (thin, livid edges, 
dilute, weakly fetid, aqueous pus). The treatment consists in free 
exposure of the infected part of the concha by means of a cutaneous 
incision in the line of insertion, passing through the fistula. After re- 
moval of the ulcerated parts with the sharp spoon, the wound cavity 
is tamponaded with formalin gauze. When there are signs of a tuber- 
culous inflammation of the external auditory meatus, it is important to 
consider the persisting scars and the possibility of a permanent stenosis 
of the auditory canal or deformity of the cavity and base of the concha. 
Other tuberculous foci which may require local and general treatment 
should also be looked for. 

4- Tuberculous Affections of the Middle Ear 

Isolated tuberculous inflammations of the tympanic membrane with 
formation of fibrous, purulent, disintegrating nodules do not often occur. 

Fig. 124. 







f 



Extensive caries of the temporal bone with complete destruction of the middle ear and formation of 

multiple fistulae. 

As a rule, the tuberculous changes of the tympanic membrane are but 
a part manifestation of tuberculous suppuration of the middle ear. 

The history usually gives no precise information on the beginning 
of the suppuration, as the tuberculous inflammation sets in painlessly 
and the affection of the ear is often not recognized until there is a puru- 



394 



THE DISEASES OF CHILDREN 



Fig. 125. 



lent secretion flowing out from the auditory meatus. The inflammation 
is characterized in many cases by a particularly small perforation. 
Perforations the size of a pin-head or a mere puncture are by no means 
rare (Fig. 127). There are also cases with multiple perforations (Fig. 

127). Tuberculous suppur- 
ation with considerable de- 
fects of the tympanic mem- 
brane nearly always belong 
to the group of those cases 
in which an originally non- 
tuberculous suppuration has 
been secondarily infected. 

The epidermal layer of 
the preserved part of the 
tympanic membrane may 
be found either intact or 




M 



Tuberculous caries of the right temporal bone of a child, four 
years old, with complete destruction of the mastoid (-V/). Ty, 
tympanic cavity. 



Fig. 126. 



ulcerated and granulating. 
The purulent secretion is 
remarkably thin and often 
highly fetid. After the tuberculous suppuration has spread to the bone 
(Figs. 123-126), all the cranial manifestations of the surgical forms of 
chronic middle-ear suppura- 
tion will of course develop 
(see p. 191). Cholesteatoma, 
pyorrhoea of the tube, and 
granulations of the pharyn- 
geal tube opening may like- 
wise appear. 

In uncomplicated cases 
the functional tests will reveal 
the signs of obstructed sound- 
conduction, and in most of 
them the hearing acuity is con- 
siderably impaired. After the 
affection has spread to the in- 
ternal ear, there will also be 
labyrinthal symptoms (slight 
hearing remnants or deaf- 
ness, vertigo, equilibrial dis- 
turbances, etc.). In extracranial complications subperiosteal abscesses 
will make a painless appearance and may attain a considerable extension, 
owing to the pus gradually lifting ever-increasing areas of periosteum from 
the bone, the connection between them being very loose in tuberculous 




Mae 

Tuberculous mastoiditis with complete disintegration of the 
corticalis and the posterior wall of the auditory meatus. Mae, 
external auditory meatus. 




AFFECTIONS OF THE EAR IN GENERAL DISEASES 395 

individuals. Thus, I observed in a tuberculous child, eight years old, a 
perforation of a tuberculous mastoid abscess through the posterior wall of 
the auditory canal. The integument of the canal, however, remained in- 
tact and was bathed in pus, which finally spread, through ossification gaps 
of the tympanic bone, to the submaxillary region and thence along the 
medial surface of the submaxillary bone to the base of the oral cavity. 
Subperiosteal, tuberculous mastoid abscesses may attain an astonishing- 
extension by spreading to the nape of the neck and the occipital and parie- 
tal bones. Mixed forms of cholesteatoma and tuberculous suppuration 
may likewise occur. Preysing has described a case of a tumor-like tuber- 
culosis of the middle ear. Tuberculosis of the 
mucous membrane of the tympanic cavity 
with an acute onset has been observed by 
Brieger, Jansen, and Kuemmel. 

The temperature is usually normal. The 
general symptoms include ill appearance, 
anorexia, and anaemia. These signs are also j 2 

observed in cases where the tuberculous otitic chronic, tuberculous suppuration 
affection is the only complaint and where the for^nTtttect'oi shraSfmen^ 
internal organs are perfectly free from tuber- ^St^S ^Zlta 

CuloSlS perforation is close below the umbo. 

2. Chronic, tuberculous middle-ear 

Course. — Tuberculous middle-ear sup- suppuration (right) ; multiple perfora- 
tion of the pars tensa. 

puration has a tendency to a chronic course 

from the onset. Three types may be distinguished: (1) Tuberculous 
middle-ear suppuration where all the characteristic signs of tuberculous 
suppuration will persist unchanged; (2) cases which set in under the 
picture of middle-ear tuberculosis but in their further course correspond 
to the non-tuberculous forms; (3) cases of apparently or positively non- 
tuberculous middle-ear suppuration in which the signs of middle-ear 
tuberculosis suddenly manifest themselves. 

Brieger's statement, "There is probably no form of chronic middle- 
ear suppuration which might not be occasioned by tuberculosis," is 
perfectly justified, especially in view of the large number of cases of 
tuberculous middle-ear suppuration in childhood. 

Koerner separates the incurable form of tuberculous middle-ear 
suppuration occurring in the terminal stage of pulmonary tuberculosis 
from curable tuberculosis of the stationary forms. 

Prognosis. — Conservative treatment may effect a complete cure in 
a small number of tuberculous cases of middle-ear suppuration (see pp. 
183 and 401). These include tuberculosis of the mucous membrane with 
an intact osseous middle ear and an otherwise perfectly healthy organism. 
In most cases, however, the osseous middle ear is likewise affected. 
Timely radical operation in these cases may not only cure the initial 



396 THE DISEASES OF CHILDREN 

tuberculosis of the ear, but also have a favorable influence upon the 
general condition. But there are also cases in which a perfect formation 
of epithelium cannot be attained in spite of a favorable healing process 
without reactions, and ulcerations with granulation will occur from time 
to time at circumscribed places of the mucous membrane of the tympanic 
cavity. 

Cases where middle-ear tuberculosis is only a part manifestation of 
a general tuberculous affection of the organism are prognostically un- 
favorable. These include chiefly the cases which are complicated by 
glandular and pulmonary tuberculosis as well as those that are associated 
with multiple caries of the skeleton. Under these circumstances middle- 
ear tuberculosis continues to spread in the ear with formation of seques- 
ters, and finally caries of the petrous bone will develop (Figs. 123-126), 
with necrosis of the labyrinth (Fig. 95) and paralysis of the facial nerve. 
The tuberculous suppuration may extend to the carotid in rare cases, 
leading to sudden death by carotid hemorrhage owing to erosion of the 
carotid artery. In most cases death is caused by an endocranial compli- 
cation (tuberculous meningitis or cerebral tumor). Tuberculous middle- 
ear suppuration may also occasionally be complicated by an acute sup- 
purative, non-tuberculous endocranial affection. 

The general nutritive condition of the patient is impaired by middle- 
ear tuberculosis in a considerable number of cases. This refers especially 
to bilateral tuberculous middle-ear suppuration with profuse secretion, 
where a tuberculous affection of the nasopharyngeal mucosa occurs 
after some time, which leads almost without exception to a rapid advance 
of the pathological process in the lungs and to rapid marasmus. But 
even grave cases of otitic tuberculosis may exceptionally recover, as 
shown in a case of Brieger, where, in spite of extensive destruction of 
the mastoid and the presence of tuberculous pachymeningitis, a cure 
was effected. 

Diagnosis. — The clinical diagnosis of tuberculous middle-ear sup- 
puration does not ordinarily meet with any great difficulties. Many 
cases are characterized by absence of pain and reactions in the begin- 
ning of the affection. The late occurrence of perforation or the presence 
of two or more perforations of the tympanic membrane (Fig. 127) may 
furnish valuable guiding points for the diagnosis. Persistence of par- 
ticularly small perforations is suspicious, when the suppuration has been 
present for a long time. Tuberculin injection may decide the diagnosis 
in many doubtful cases.' A negative reaction to a puncture of 1 mg. 
tuberculin definitely excludes active tuberculosis. Positive puncture 
reaction as well as the Pirquet reaction, however, does not admit of a 
conclusion as to the nature of the otitic affection. Microscopic demon- 
stration of tubercle bacilli in the pus taken from the ear will only sue- 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 397 

ceed in exceptional cases. Histological examination of the granulations, 
however, will always admit of a positive diagnosis of tuberculous middle- 
ear suppuration by the demonstration of characteristic tuberculous 
giant cells or of tubercle bacilli in the tissue, which stain after Ziehl. 
The bacteriological examination of a local lymph-gland, which may be 
removed on the occasion of a radical operation, may at times confirm 
the diagnosis of tuberculosis of the ear. Ear polypi, however, but rarely 
show characteristic histological signs of tuberculosis. 

Conservative Treatment. — The conservative treatment of tuber- 
culous middle-ear suppuration does not materially differ from the treat- 
ment of the non-tuberculous form. The application of strong antisep- 
tics (iodoform, iodol, etc.) should be continued for a long time. Many 
authors recommend instillation of 30 per cent, lactic acid or 1-2 per 
cent, trichloracetic acid solutions. Insertion of cotton plugs moistened 
with balsam of Peru or cauterization with concentrated aqueous picric- 
acid solution, lactic acid, or chromic acid sometimes leads to rapid and 
considerable diminution of the secretion. Furthermore, irrigations with 
aqueous formalin or sublamine solutions (1 Gm. of commercial concen- 
trated formalin solution to 1 pint of water, sublamine solution 1 to 1000) 
and insertions of gauze saturated with formalin, sublimate, or sublamine 
are to be recommended. In other cases the stagnation and aspiration 
treatment seems to have a favorable effect. Conservative treatment 
may lead to complete cure if the tuberculous suppuration has been 
confined to the mucous membrane of the middle ear or the osseous parts 
of the middle ear are affected at superficial and easily accessible places, 
especially if the patients are otherwise healthy and robust. 

A valuable adjuvant is the local application of light. A hard- 
rubber funnel of the greatest admissible amplitude is introduced into 
the auditory meatus and the patient brought into such a position that 
the full sunlight may enter the funnel, while the rest of the head is pro- 
tected against the sun's rays. This may be done in the open air, weather 
permitting. A metal or glass reflector will serve to conduct the rays into 
the ear when the proceeding takes place in a room. When the weather is 
dull or cold, the Auer lamp may be used. The results of illumination 
are exceedingly favorable, not only in conservative treatment, but also 
in the treatment after operations, as it leads to considerable reduction 
of the secretion and rapid formation of epithelium. I have not seen any 
advantage from employing blue light. 

General invigorating treatment is of fundamental importance in 
all cases of middle-ear tuberculosis. If it is possible by dietary means 
to effect an increase in body weight, the chances of a cure in tuberculous 
middle-ear suppuration are favorable. In order to make sure of correct 
general treatment, it is advisable to place patients in an institute for 



398 THE DISEASES OF CHILDREN 

tuberculosis, provided there is an ear specialist attached to it who is 
conversant with the methods of treatment. Otherwise a stay in the 
country in a warm, dry, and wind-protected district, together with 
milk treatment and a fattening diet, is often attended with remarkable 
success. 

Indications for Operation. — Surgical interference in tuberculous 
middle-ear suppuration should be considered if, after one or two weeks' 
conservative treatment, fetid suppuration should continue and all those 
manifestations occur which have been mentioned when discussing the 
surgical forms of chronic middle-ear suppuration. Operation, however, 
should only be resorted to if the general condition of nutrition is favor- 
able and there is no fever. Where the suppuration has not existed for 
more than a year and the condition of the patient is satisfactory, antrot- 
omy will be found sufficient; attico-antrotomy is indicated if there be 
changes in the attic. In all other cases the typical radical operation 
should be carried out. A successful operation depends upon the question 
whether all the affected bony parts have been removed and also on the 
condition of the patient previous to operation. A favorable prognosis 
may be made for those cases whose weight could be increased before the 
operation by appropriate diet. The healing process in these cases does 
not ordinarily differ from that in radical operation in non-tuberculous 
middle-ear suppuration. Less favorable is the prognosis in cases where 
the nutritive condition has been impaired through many years of suffer- 
ing and where an increase in weight before operation does not occur as a 
result of appropriate diet. In a considerable number of these cases, 
however, the radical operation exercises a visibly favorable influence 
upon the nutritive condition, effecting a rapid increase in weight. The 
healing process is rapid in some cases, while in others it takes from 
six to eight months before complete recovery. In those few cases where 
the epidermis is not completely restored, we must content ourselves 
with the fact that the secretion from the middle-ear spaces is no longer 
fetid, that it can be satisfactorily drained off, and that in the course of 
time it assumes a purely mucous character. Unfortunately, this ulcer- 
ation of epithelialized places from time to time cannot be prevented, as 
the new-formation of epithelium goes on. But even in these cases the 
favorable effect of removing the otitic focus upon tuberculous foci in 
other parts of the body can be recognized as well as the favorable in- 
direct influence of the radical operation upon pulmonary and glandular 
tuberculosis, should such exist. 

Prognostically unfavorable are those cases in which advanced 
middle-ear tuberculosis is associated with multiple caries of the skeleton 
or progressive pulmonary tuberculosis. Operation will then be resorted 
to only in cases of urgent necessity owing to a complicating endocranial 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 399 

affection or labyrinth suppuration. A cure of the otitic tuberculosis 
is out of the question in these cases. Greatly debilitated individuals 
will only slowly recover from the operation. The operative wound is 
almost of a cadaverous odor during the first few weeks; there is practi- 
cally no traumatic secretion, merely a sparse, viscid layer. These patients 
may give the impression as if the skeletal, glandular, and pulmonary 
tuberculosis had actually become worse by the operation, owing to the 
general debilitation of the patient. In advanced middle-ear tuberculosis 
and extension of the affection to the cranial surfaces of the temporal 
bone and labyrinth, there is also the imminent danger of tuberculous 
meningitis or cerebral tuberculosis setting in, both of which nearly always 
run a fatal course. 

5. Tuberculous Infections of the Internal Ear 

Habermann, Herzog, Kuemmel, and Politzer agree in pointing out 
the frequent involvement of the labyrinth in tuberculous suppuration 
of the middle ear. 

Tuberculous suppuration of the labyrinth may underlie an involve- 
ment of the labyrinth, but cases have also been reported where tuber- 
culous middle-ear suppuration was associated with non-tuberculous 
suppuration of the labyrinth. 

Anatomy. — Tuberculous suppuration of the labyrinth may be con- 
fined to some part of the labyrinth for a long time and only become 
diffuse at a subsequent period. In the early stages of the affection there 
is a serous exudate in the labyrinthal spaces, swelling of the membranous 
walls of the labyrinth, and inflammatory infiltration. Simultaneously, 
or shortly afterward, the sensory cells of the labyrinthal nerve-end 
places are destroyed. Later changes include accumulation of pus in 
the labyrinth spaces, secretion of a fibrinous exudate, and the partial 
obliteration of the labyrinth spaces by connective-tissue proliferation. 
These changes in the hollow spaces of the labyrinth are accompanied by 
changes in the osseous capsule and the petrous bone, but the para- and 
endolabyrinthal inflammatory manifestations do not occur simultan- 
eously, and the time of their appearance differs in individual cases. As 
a rule, the tuberculous suppuration of the petrous bone precedes that 
of the membranous labyrinth. 

The suppurative destruction of the bone is also associated with 
sequestration, which may involve all parts of the labyrinth. Small 
sequesters of the promontory, modiolus, and facial canal may be expelled 
through the external auditory meatus, while large labyrinthal seques- 
ters usually remain for a long time in their normal topographic position. 
The suppurative destruction of the bone causes granulation and the 
sequesters are infiltrated with granulations. In sequestration of the 



400 THE DISEASES OF CHILDREN 

cochlea or of the entire labyrinth, all the hollow spaces of the latter 
may be replete with granulations. The suppuration of the labyrinth 
even spreads to the auditory canal in a few cases, leading to purulent 
infiltration and in chronic cases to purulent decomposition of the nerve 
tuft. Labyrinthal fistulse are of exceedingly frequent occurrence, most 
of which are of the centrifugal variety (see p. 224), which do not appear 
until the labyrinth has completely exulcerated by outward perforation 
of the endolabyrinthal abscess. Sequestration of the labyrinth also 
leads to purulent infiltration and later to complete disintegration of the 
facial nerve in certain cases. 

Symptoms. — The symptomatology of tuberculous suppuration of 
the labyrinth does not differ from the non-tuberculous forms except 
that it has a tendency to chronicity and sets in insidiously similar to 
tuberculous middle-ear suppuration. This may account for the fact 
that the intensity of the characteristic labyrinthal symptoms is only 
slight and some symptoms may be entirely absent. 

The impairment of the hearing ability induced by the middle-ear 
suppuration gradually increases and terminates in total deafness. Sud- 
den deafness does not often occur in tuberculous suppuration of the 
labyrinth. The vertigo has all the characteristic signs of the labyrinthal 
variety, but, as a rule, is not very intense and does not occur in abrupt 
paroxysms, but rather in a chronic form. Labyrinthal disturbances of 
the equilibrium are always present in diffuse tuberculous suppuration 
of the labyrinth, in the circumscribed form, however, only when the 
static labyrinth has been involved. The temperature is usually normal. 
There is often headache on the affected side. 

Paralysis of the facial nerve may occur in the beginning of tubercu- 
lous labyrinthitis or during its course, and is occasioned by the fact that 
a tuberculous paralabyrinthal focus has spread to the facial canal. 
Cases of extensive caries of the petrous bone, however, have also been 
reported where the facial nerve was intact. 

Course. — Tuberculous suppuration of the labyrinth is character- 
ized by a pronounced chronic course. Spontaneous cure is not impos- 
sible if the suppuration is confined to the hollow spaces of the labyrinth 
and the petrous bone remains normal, especially on the surfaces facing 
the cranial fossa?. These favorable cases heal with complete destruc- 
tion of the labyrinthal nerve-end places and partial or complete obliter- 
ation of the labyrinth by connective tissue which later changes into 
osseous substance. In other favorable cases healing occurs after expul- 
sion of a number of small sequesters, often amounting to 10 or 15. Cases 
where endocranial fistulse develop take an unfavorable course, as they 
involve the danger of the tuberculous suppuration spreading to the 
endocranium. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 401 

Diagnosis. — The diagnosis of suppuration of the labyrinth as such 
does not present any particular difficulties, but its tuberculous character 
cannot usually be recognized with certainty before operation. The clin- 
ical signs of the tuberculous character of the middle-ear suppuration and 
the expulsion of labyrinth sequesters are aids to diagnosis ; the protracted 
course and relatively slight intensity of the labyrinth symptoms, as well 
as the permanently normal temperature, likewise favor the assumption 
of a tuberculous process. 

Treatment. — Immediate radical operation in the early stages of 
labyrinthitis is indicated. If the symptoms are fully developed on 
admission of the patient, a waiting attitude is in order except in the 
presence of complications. Rest in bed is prescribed, and the paroxysms 
are tentatively controlled by the galvanic current. They are relieved 
and shortened by darkening the room and placing the patient in the 
most favorable position (see p. 269). These measures are accompanied 
by extremely careful conservative treatment of the tuberculous suppura- 
tion of the middle ear with a view to securing free evacuation of the pus. 
After the labyrinthal symptoms have subsided, the radical operation or, 
if indicated, resection of the labyrinth may be proceeded with. 

In cases of complicated tuberculous labyrinthitis immediate resec- 
tion of the labyrinth is indicated, although the result is not expected to 
be satisfactory. The result of the operation itself is often favorable 
enough, in spite of extensive resection of the petrous bone, but for weeks 
or months afterward there is considerable danger of tuberculous menin- 
gitis setting in, to which the patient will succumb. 

B. SYPHILITIC AFFECTIONS OF THE EAR 

1. Acquired Syphilis in Childhood 

Acquired syphilitic affections are rare in infancy and childhood. They 
are nearly always occasioned by extragenital infections by kissing, using 
eating and drinking utensils of syphilitic individuals, or by secondary trau- 
matic infection. Nurslings have been infected by syphilitic wet-nurses. 

This form of syphilis rarely extends to the ear. Here and there 
syphilitic roseola of the concha, with circumscribed papules, has been 
observed. Both dry and exuding papules may occur at the external 
auditory meatus. 

The local treatment consists in insertions of gray ointment and 
painting with iodoform and sublimate. Energetic antisyphilitic treat- 
ment promptly effects a cure. 

I have never observed condylomata of the external auditory meatus, 
pustulous syphilides, or gumma in the auricular region of children, nor 
any inflammatory middle-ear affection which could have been accepted 
as acquired syphilis free from objection. 

VI— 26 



402 THE DISEASES OF CHILDREN 

One case of chronic middle-ear suppuration, however, deserves 
mention. An extragenital, syphilitic infection occurred in earliest 
infancy. The child was treated and acquired at the age of five a middle- 
ear suppuration which became chronic in spite of treatment. After 
institution of antisyphilitic treatment the middle-ear suppuration was 
promptly cured. 

Syphilitic affections of the labyrinth or eighth nerve in acquired, 
extragenital syphilis in childhood have not come within the range of 
my observations, but it may be assumed that the course and prognosis 
of such affections are perfectly identical with syphilitic affections of the 
internal ear in adults. For this reason a detailed discussion of these 
affections may be dispensed with at this place, and I refer, in regard to 
treatment, to my treatise on syphilitic affections of the ear in the "Hand- 
book of Sexual Diseases." 

2. Hereditary Syphilitic Diseases of the Middle Ear 

Hereditary syphilitic affections of the middle ear are far less promi- 
nent than similar manifestations of the internal ear in regard to fre- 
quency and clinical importance. 

Asai concluded, from his anatomical investigations of the ears of chil- 
dren with hereditary syphilis, that the latter does not predispose the foetus 
or new-born to middle-ear inflammations. The frequency and nature of 
otitis media are the same whether the ear is or is not infected with 
hereditary syphilis. 

Among the middle-ear infections, suppurations with a grave course 
are most frequently observed, but they are only indirectly caused by 
hereditary syphilis. They usually occur in nurslings who present the 
typical nasopharyngeal changes of hereditary syphilis and are caused by 
the latter. The unfavorable prognosis of these cases is occasioned by the 
inferior nutritive condition of all nurslings with grave general manifes- 
tations of congenital syphilis. 

Children with congenital syphilis sometimes suffer from exudative 
middle-ear catarrh. In some cases this does not differ from the ordi- 
nary, non-syphilitic, exudative catarrh, and is occasioned by naso- 
pharyngeal changes. Occasionally, however, such an exudative catarrh 
partakes of a specific nature and appears to be a part manifestation of a 
syphilitic affection of the middle ear and labyrinth. This is evidenced 
by the fact that after resorption or evacuation of the exudate there is 
only slight or no improvement of the hearing ability, and the middle- 
ear symptoms are gradually replaced by those of an affection of the 
internal ear. 

These apparently catarrhal affections develop into affections of the 
labyrinth or ear which clinically correspond to the type of otosclerosis. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 403 

Note. — The affections of the external ear in hereditary syphilis 
perfectly correspond to those of the integument which have been ac- 
quired intra uterum. Therefore, they do not differ from acquired syphi- 
litic affections of those regions. 

3. Affections of the Internal Ear in Hereditary Syphilis 

Owing to their relative frequency in infancy, their grave course, 
and peculiar findings, affections of the inner ear and eighth nerve in 
hereditary syphilis command considerable clinical interest. Authors 
differ as to frequency. According to my own observations, about 6 per 
cent, of infants with hereditary syphilis suffer from an affection of the 
sound-perceiving apparatus, with a high degree of dysacusis, deafness, 
or considerable labyritithal vertigo. Slight lesions of the internal ear 
in congenital syphilis which are associated with tinnitus aurium with 
normal or slightly impaired hearing acuity, with slight labyrinthal 
vertigo and equilibrial disturbances, are far more frequent. 

Anatomy. — The anatomical foundation of affections of the internal 
ear in hereditary syphilis is not yet quite understood. There is no 
doubt that there are several anatomical types. The first place is occu- 
pied by degenerative neuritis of the eighth nerve, next follow processes; 
in the acoustic labyrinth itself which are accompanied by exudation and 
coagulation in the spaces of the acoustic labyrinth or by labyrinthal 
hemorrhages and rapidly lead to degeneration of the neuro-epithelium 
and the nerve branches. Another type consists in congenital changes 
of the osseous capsule of the labyrinth, which are probably the result 
of an inflammatory syphilitic affection of the bones which the fcetus has 
undergone in intra-uterine life. The histological changes seem to be 
identical with those found in other bones. Meningitic changes in the 
new-born which, according to Mayer, may cause interstitial inflammation 
of the eighth nerve and subsequent development of an otitic affection 
are likewise due to intra-uterine, syphilitic inflammation. The case 
observed by Haike likewise belongs to this group. Asai has made his- 
tological examinations of the ears of fourteen cases with hereditary 
syphilis, raDging from a seven-months fcetus to two-months-old infants. 
The cadaver of a three-weeks-old infant with hereditary syphilis showed 
signs of a recent pachymeningitis and labyrinthitis, but he could not 
find in a single case any syphilitic changes of the blood-vessels or patho- 
logical hemorrhages of the ear. 

Etiology and Occurrence. — It is not yet definitely decided whether 
luetic endarteritis in childhood is an etiological factor in the occurrence 
of affections of the labyrinth and eighth nerve. Nor is the cause of the 
location in the internal ear ascertained. The otitic affection occurs 
sometimes as a sequel to severe traumas or infectious diseases, this 



404 THE DISEASES OF CHILDREN 

factor, however, being only an indirect cause of affections of the ear 
and eye in children with hereditary syphilis. Thus, the majority of 
cases of deafness and blindness are etiologically traceable to hereditary 
syphilis. 

The most severe forms of hereditary syphilis seem to be acquired 
during intra-uterine life, the new-born in these cases showing all the 
signs of congenital deafness and non-excitability of the static labyrinth. 
A more or less light degree of impaired hearing in young children with 
hereditary syphilis is of frequent occurrence during the first few years 
of life. At first it remains stationary, and does not usually undergo any 
exacerbation until puberty or at the age of eighteen to twenty, when it 
may degenerate into pronounced dysacusis or deafness. 

A third type of syphilitic affection of the labyrinth consists in slightly 
impaired hearing with tinnitus aurium, or merely in tinnitus without 
any appreciable impairment of the hearing faculty. Gradual deteriora- 
tion of the latter may occur, but many of these cases admit of a good 
prognosis in regard to hearing acuity. These three otitic affections do 
not often occur singly, they being usually associated with Hutchinson's 
teeth and interstitial keratitis, or either. The manifestations of the 
internal ear sometimes occur in an apoplectiform way without any 
prodromal signs, or at least only with such prodromal signs as escape 
the attention of the parents, and lead in a few days or weeks to total 
bilateral deafness, followed by deaf -mutism in earliest childhood. This 
type is nearly always associated with interstitial (parenchymatous) 
keratitis, the latter usually setting in after the otitic affection has run 
its course. In regard to other points, the extent of the labyrinthal affec- 
tions varies. In most cases the cochlearis and vestibularis are affected, 
so that the symptoms of both are present. The vestibular disturbances, 
however, are often slight, and the reflex excitability of the static laby- 
rinth is preserved, while the affection in the region of the cochlearis 
attains to a high degree and terminates in complete elimination of 
physiological function, which means deafness. 

Next come those cases where deafness occurs together with loss of 
excitability of the static labyrinth, the entire internal ear having lost 
its function. As mentioned above, isolated slight cochlear and vestibular 
affections are very frequent in hereditary syphilis. 

The characteristic changes of the reflex excitability of the vestib- 
ularis will be referred to presently. 

Otoscopic Findings and Functional Test. — As a rule the tympanic 
membrane is perfectly normal, in other cases osmotic, and sometimes ex- 
hibits a reddish glistening in the region of the promontory. Should the mid- 
dle ear be simultaneously affected, there will, of course, be many catarrhal 
or purulent inflammatory changes of the tympanic membrane and cavity. 



AFFECTIONS OF THE EAR IN GENERAL DISEASES 405 

The functional test presents the picture of an affection of the sound- 
perceiving apparatus, but there are two very characteristic peculiarities 
which in doubtful cases may lead to the diagnosis of hereditary syphilis. 
All investigators have found a relatively great reduction of the cranial 
conduction of the cochlear part. I have also found this to be the case in 
all the cases I have observed; even in slight impairment of hearing and 
slight affection of the internal ear, the sound-perception through the 
cranial bones is considerably shortened in hereditary (and often also 
in acquired) syphilis. 

As to the static labyrinth, abnormalities in the reflex excitability 
of the semicircular canals are of frequent occurrence in hereditary syphilis. 
The first place is occupied by positive compression or aspiration nystag- 
mus (positive fistula symptom without a fistula). In affections of the 
labyrinth due to hereditary syphilis in which there never was any sup- 
purative affection of the ear, nor any manifestations of the static laby- 
rinth, the fistula symptom without the presence of a fistula may be 
observed in some cases. This is evidently due to changes of the excitable 
parts of the nerve terminations of the static labyrinth. In normal 
individuals compression or aspiration of the air in the external auditory 
meatus only influences the function of the cochlea (Gelle's test), while 
compression and aspiration in the normal static labyrinth has no physio- 
logical effect. In labyrinthal affections due to hereditary syphilis a 
positive fistula symptom can often be elicited; it may occur periodically 
either in compression or aspiration (see p. 237). 

Diagnosis. — The diagnosis is not beset with any difficulties. The 
other signs of hereditary syphilis, notably the previous parenchymatous 
keratitis and the changes of the upper inner incisors, lead to the correct 
diagnosis. The diagnosis is verified by a positive Wassermann test, 
which is peculiarly suitable for the diagnosis of congenital syphilis and 
is positive in the majority of all cases. 

Characteristic signs are the occurrence of the affection in childhood, 
the rapid development of the pathological manifestations, and the above 
symptoms elicited by the functional test, consisting in unusual reduction 
of the cranial conduction and fistula symptoms without a fistula. Doubt- 
ful cases may be elucidated by the family history and, if possible, exam- 
ination of the parents. 

In establishing the differential diagnosis, there is first the so-called 
idiopathic atrophy of the auditory nerve to be considered. This affec- 
tion is very rare, and many cases which were formerly interpreted as 
such would at the present time show a positive Wassermann reaction 
and be recognized as hereditary syphilis. 

The next affection to be considered is hereditary non-syphilitic hard- 
ness of hearing which is usually of a light degree. I have observed and 



406 THE DISEASES OF CHILDREN 

reported a case of this kind (see p. 234). With aid of the Wassermann 
test the correct diagnosis may be arrived at at once. Besides, inter- 
stitial keratitis and the changes of the incisors are, of course, absent in 
non-syphilitic cases. 

Atypical cases of otosclerosis should be considered in the differen- 
tial diagnosis. The latter can be made from a negative Wassermann, 
from the insidious onset and course of the affection, which will not 
exhibit a pronounced degree until puberty, and from the fact that in 
otosclerosis the involvement of the static labyrinth nearly always occurs 
at a late stage. The family history should also be considered, as it may 
show the tendency to hereditary otitic affections (progressive hardness 
of hearing or deafness, but no deaf-mutism in preceding generations, nor 
syphilis). 

Treatment. — The general treatment claims principal attention. 
Immediate salvarsan treatment is indicated in all cases of grave affec- 
tions of the labyrinth and auditory nerve. In light, fresh cases salvar- 
san is best preceded by mercury treatment. 

Should any exacerbations occur during or after salvarsan treatment, 
continuation of the antisyphilitic treatment is urgently recommended. 
My position on this question is still to apply first inunction or subli- 
mate injections and follow this up by salvarsan, while other authors 
recommend the immediate application and repetition of salvarsan in- 
jections. However, the selection of the remedies (mercury and iodide) 
and their dosage have to be adapted to the peculiarities of each case, 
the constitution of the child, etc. As to the details of the various meth- 
ods, the text-book on syphilography should be consulted. Galvanic 
treatment of the eighth nerve seems to arrest the advance of degenera- 
tive changes of the nerve. Children should have 2-4 ma. with both elec- 
trodes applied to the tragi three times weekly for four to six weeks, each 
application to last five minutes. I have not seen any favorable results 
from pilocarpine injections in otitic affections of heredo-syphilitic origin. 

The prognosis is not favorable in the majority of cases. In a number 
of cases the affection of the labyrinth may remain stationary, or even be 
cured, with good hearing function. A perfectly normal acuity with 
sensitive function, however, has never returned in any of the cases. In 
most of them a gradual or sudden deterioration will set in, terminating 
in unilateral or bilateral dysacusis or total deafness. The stormier the 
onset of the labyrinthal manifestations the more unfavorable is the 
prognosis. An improvement of high degrees of dysacusis or total deaf- 
ness will not occur by local or general treatment except in the rarest 
of cases, and then only in fresh ones. 



XVn. IMPAIRED HEARING DURING SCHOOL LIFE. THE 
SCHOOL OTOLOGIST 

The strides made in the education of the deaf-mute have caused 
attention to be paid to this question in the schools. Bezold has shown 
the influence of impaired hearing on the mental development of school 
children on the basis of comprehensive statistics. He has shown that 
school instruction is attended with far inferior results in children whose 
hearing faculty is impaired than in normal ones, unless due regard is 
paid to the affliction. 

In German and Austrian schools a rule was established many years 
ago for hard-hearing children to sit on the front bench, so as to facilitate 
their participation in the lessons. If the affection is of such a pronounced 
degree that in spite of this rule a child is unable to follow the lessons, an 
arrangement can be made in classes with a small number of pupils for 
the former to sit in immediate proximity to the teacher. In the public 
schools of large cities this arrangement can, of course, not be carried 
out without disturbing the lessons. 

Hartmann was the first to point out that the establishment of special 
classes for pupils very hard of hearing is not only advisable, but urgently 
necessary. 

When, in Berlin, classes for children with impaired hearing were 
established, after the school physician had directed attention to the sub- 
ject, the teachers were requested to- send hard-hearing pupils, who could 
not follow the lessons, forward for examination. In a district contain- 
ing 23,000 pupils, 45 were selected for examination, but only 30 were 
admitted. Some of the remaining 15 could be improved by appropriate 
treatment ; in the rest of the cases parents refused to have their children 
sent to special classes. The 30 children were instructed by two teachers 
in two sections. 

From this experience it may be assumed that, in towns of 150,000- 
200,000 inhabitants, special schools should be established for children 
with impaired hearing. 

Children commanding a hearing distance of 3 feet 4 inches to 1 
foot 8 inches for whispered language can still follow the lessons in public 
schools, but most of those whose hearing distance is reduced further 
should be placed in special classes for hard-hearing pupils or receive 
private lessons. 

Hartmann further points out that those acoustically afflicted should 
be examined by a competent specialist and that, if necessary, treatment 

407 



408 THE DISEASES OF CHILDREN 

of the underlying affection should be taken in hand. The pupils assigned 
to a special class should be seated near the teacher, and these classes 
should not hold more than 10-15 pupils. If a child suffers from such a 
high degree of deafness that he cannot follow the lessons in a special 
class, he should be placed in an institution for the deaf and dumb, 
assuming, of course, that in such institutes in large cities the lessons are 
based on the hearing principles for children who still possess serviceable 
hearing remnants. 

All the pedagogic arrangements which tend to promote the educa- 
tional facilities of the children presuppose a well-organized medical 
service. The function of the school physician has occupied the fore- 
ground of school-hygienic questions for a number of years. 

In June, 1908, the Austrian Society for the Education of Children 
sent out a question blank with reference to the school physician, the 
principal object of which was to establish the way a medical service 
in the schools of large cities could be promptly established. 

The organization of the medical school service in Berndorf, in 
Lower Austria, is a model arrangement. 

In answer to the question blank referred to, Dr. Dehne reported 
his experience in connection with the medical school service in Berndorf. 
This experience comprises a period of four years, and has shown that 
Dr. Dehne has instituted and carried out that service in an excellent 
manner. 

One of the city physicians acts as school physician. Specialists are 
engaged for the examination of the ear, eye, and teeth. The additional 
engagement of an orthopaedist would be desirable. 

In my capacity as school otologist I undertake the examination of 
the ears, nose, and fauces every Saturday and Sunday during the month 
of May. The ear has already been included in the general physical 
examination made by the school physician, so far as otoscopic findings 
and hearing acuity are concerned, likewise the nose, fauces, and speech. 
He determines which children should be sent to the otologist. In urgent 
cases a special examination, of course, takes place immediately. Should 
extensive surgical measures be necessary, the child is sent by the school 
physician to my department at the General Policlinic in Vienna. Bern- 
dorf has an ear clinic for school children since 1909, thanks to the munifi- 
cence of Arthur Krupp. It is equipped with all modern appliances. 

A short history is established in each case, and I determine the 
hearing acuity, the tuning-fork test, and, if necessary, the functional 
test of the labyrinth, according to the methods of clinical tests described 
on p. 96. 

The school otologist has also to pay the greatest attention to an 
examination of the nose and nasopharyngeal space, aside from examin- 



IMPAIRED HEARING DURING SCHOOL LIFE 409 

ing the ear. My experience in Berndorf has shown that up to the period 
of puberty hypertrophy of the tonsils undergoes spontaneous involution 
in but a very small number of cases. It has also shown that the fre- 
quency of catarrhal middle-ear affections considerably decreases during 
school age. According to the statistics of 1908, children with hyper- 
trophic tonsils between the ages of six and seven include 85 per cent, 
of catarrhal middle-ear affections, as against 29 per cent, between the 
ages of thirteen and fourteen, although the etiologically important 
changes (hypertrophic tonsils and adenoid vegetations) had not under- 
gone any material change in the meantime. On the other hand, the 
percentage of cases with middle-ear suppuration in the presence of 
hypertrophic tonsils considerably increases during school age. As the 
danger of catarrhal middle-ear affections during school age decreases, 
the danger of suppurative otitis media increases; in fact ; the decrease 
in the percentage of catarrhal middle-ear affections is exceeded by the 
increases in the percentage of suppurative middle-ear affections. 

It cannot, therefore, be asserted that the danger of hypertrophic 
tonsils for the growing child decreases during school age; on the con- 
trary, the danger increases. The danger in the first period of school 
life, from the seventh to the eleventh year, lies in catarrhal middle-ear 
affections, which is superseded in later years by the danger of suppura- 
tive otitis media. 

It may be objected that the greater frequency of the latter affection 
is due to the infectious diseases which children usually acquire during 
that period, but it should be remembered that even in these cases the 
hygienic condition of the nasopharyngeal tract is the most important 
factor: a child with a healthy nasopharyngeal tract will, in the course 
of scarlet fever, measles, diphtheria, etc., not acquire suppurative otitis 
media as easily as one with hypertrophic tonsils, adenoid vegetations, 
and impaired or obstructed nasal respiration. 

It follows of necessity that hypertrophic tonsils should "be removed 
so soon as they impair normal respiration or the physiologic ventilation 
of the tympanic cavity. 

The correctness of this statement was confirmed during an epidemic 
of scarlatina and measles in Berndorf in the winter of 1909-1910. Among 
the patients there were several children whose hypertrophic tonsils and 
adenoids I had removed one or two years previously: not one of these 
contracted an acute middle-ear suppuration in the course of the infec- 
tious diseases. 

The percentage of children with permanently reduced hearing acuity 
increases during the school period, but this percentage can be reduced 
to a minimum by methodical examination and competent treatment 
commencing at school age. 



410 THE DISEASES OF CHILDREN 

It is necessary, in the interests of a successful activity of the school 
otologist, that teachers and parents be advised on hygienic questions 
concerning the ear. The school physician, or another suitable teacher, 
should deliver lectures from time to time on personal hygiene (soma- 
tology), including the hygiene of the ear. A useful arrangement for 
larger cities would be for the school otologist to deliver an annual lecture 
before the pupils collected from several schools, and their parents, on 
the hygiene of the ear and the nasopharyngeal tract. 

The school otologist examines the children, if possible, in the pres- 
ence of the school physician and the parents. The invitations to attend 
the examinations distinctly state that the examination is not compul- 
sory. After the examination the school otologist makes his diagnosis 
and decides upon the form of treatment. 

The conservative treatment is delegated to the family physician, 
preferably in an interview between the school otologist, the school 
physician, and the family physician. This interview should take place 
after a large number of examinations have been made. If desirable, a 
member of the teaching staff may also be invited to attend. The school 
or family physician will undertake to inform parents of the decision of 
the school otologist in regard to the necessity of surgical interference, 
and obtain their consent. It is advisable to compile the salient points 
concerning the hygiene of the ear in a special circular for the use of 
children, parents, and teachers. 



Index 



PAGE 

Abducens 269 

paresis 351 

Abducent paralysis 297 

Abnormal excitability of semicircular 

canals 237 

Abscess, cerebellar. .211, 273, 293, 329, 

330, 338, 353 

cerebral 260 

cranial 293 

descending, within sternocleidomas- 
toid 288 

diploic 277 

endolabyrinthal 400 

extradural 167 

fetid 168 

formation 127 

in pars mastoidea 163 

of mastoid process 172 

tuberculous 392 

Abscesses, actinomycotic 281 

daughter 349 

descending, of neck 276 

endolabyrinthal 400 

extradural 260, 294 

initial 297 

latent 297 

manifest 297 

gaseous 168 

intradural 330 

intrameningeal 327, 330 

mastoid 168, 169, 287 

of muscles of abdomen 321 

osteomyelitic 321 

otitic, of temporal lobe 211 

descending 308 

otogenic 342 

cerebellar 347 

perforating 276 

perisinous 306, 386 

peritonsillar 287 

of posterior cranial fossa 294 

subarachnoid 328 

Abundant granulation of middle ear .... 163 
Accouplement of healthy consanguine- 
ous animals 239 

Accumulation of cerumen 117 

Acoumeter 64 

Acoustic and static tests, survey of the . . 96 
Acquired atresia of external auditory 

meatus ^ . . . 108 



PAGE 

Acquired deafness 245 

resulting from measles 254 

from scarlet fever 254 

syphilis in childhood 401 

Acromegaly 238 

Actinomycotic abscesses 281 

Acusticus 212 

tumor 211 

Acute catarrh of middle ear 132 

of tube 135 

of tympanum 136 

degeneration in typhoid 269 

dermatitis Ill 

exudation of labyrinth 365 

exudative catarrh of middle ear 385 

infantile mastoiditis 179 

otitis 159, 162 

inflammation of deep lymph-glands of 

neck and nape 290 

of middle ear, anatomy and etiology 

of 146 

keratitis 327 

lymphomatosis 365 

muscular rheumatism 290 

myringitis 133, 388 

otitis 388 

media 5, 146, 309 

course 148 

diagnosis 149 

epitympanic type 147 

functional test 148 

mesotympanic type 148 

symptoms 147 

paralabyrinthitis 262 

purulent perichondritis 114 

course 115 

diagnosis 115 

result 116 

symptoms 115 

treatment 115 

serous inflammations of labyrinth . . . 269 
and subacute catarrh of middle ear. . . 136 

suppuration of middle ear 151 

course 153 

symptoms 153 

suppurative cholesteatoma 217 

mastoiditis 308 

paralabyrinthitis 223 

tubal catarrh ISO 

typhoid otitis 384 

411 



412 



INDEX 



PAGE 

Adenoid vegetations 135 

Administration of thyroidin in cretinic 

deafness 374 

Adrenalin plugs, use of, in affections of 

ear 376 

Advanced education for deaf-mutes .... 249 
Aerobic or anaerobic micro-organisms. . . 329 

Affection of venous sinuses 172 

Affections of ear in acute infectious dis- 
eases 375 

in diphtheria 380 

in epidemic parotitis (mumps) 381 

in general diseases 365 

in lymphatic constitution and rha- 

chitis 366 

in other acute infectious diseases . . . 388 

in scarlet fever and measles 376 

internal ear in hereditary syphilis .... 403 

semicircular canals 54 

disturbances of equilibrium 54 

nystagmus 54 

vertigo 54 

After-treatment following radical opera- 
tion in affections of middle ear 206 

Air-conduction 48 

meato-tympanic 48 

pharyngo-tympanic 48 

Air-douche 60 

Airol, use of, in eczema 124 

Alypin, use of, in anaesthesia of ear 98 

Amnestic aphasia 297, 342 

Ampullae 259 

Amylum, use of, in eczema 124 

Anaemia 121, 207 

Anaesthesia of ear 97 

alypin 98 

anaesthesin 98 

cycloform 98 

electrolysis 98 

novocaine 98 

in operation for abscess formation. ... 127 

paracentesis 98 

in tuberculous perichondritis 392 

Ansesthesin, use of, in anaesthesia of 

ear 98 

in furunculosis 124 

Anastomosis 219 

of blood-vessels 113 

successful end-to-end 220 

Anatomical changes in acute mastoidi- 
tis 166 

signs of complicated diffuse suppura- 
tion of labyrinth 377 

Anatomy of eighth nerve of ear 46 

temporal bone of ear 1 



PAOB 

Anencephalia 240 

Anencephaly 104, 222 

Angina 308 

Angioma of lobule 391 

Angiosarcoma 211 

Angle and fundus, cleansing of 197 

Annulus tympanicus 121 

Anomalies of labyrinth 234 

Anorexia 172, 274 

Antero-inferior torsion 170 

Antrotomy 120, 179, 263 

Antrum triangle 203 

Anus, eczema at 121 

Apex, removal of 177 

Aphasia ., 372 

Aphonia 372 

Aquaeductus vestibuli 224 

Arrest of development in Corti's organ. . 369 
Arrested development in congenital deaf- 
ness 104r 

Articulation 65, 244 

with maximal pressure of expiration . . 65 

with relaxed vocal cords 65 

with tension of vocal cords 65 

Artificial tympanic membranes 187 

Ascophora in meatus 116 

Aspergillus in meatus 116 

Aplasia of thyroid 369 

Apoplectic vertigo 51 

Apoplectiform deafness caused by hemor- 
rhages 366 

hemorrhages of labyrinth 365 

non-traumatic hemorrhages of laby- 
rinth 269 

Application of heat 150 

Aquaeductus cochleae 224 

Aspiration 146 

nystagmus 237 

Athyroid cretins 368 

Atrophy of facial skin 217 

of stria vascularis 241 

of tympanic membrane 60 

Attico-antrotomy 198, 210 

Atticoscopy 201 

Auditory acuity. . . . . . 192 

determination of 64 

meatus 205 

Auricular eczema, acute 121 

chronic 121 

sensory aphasia 368 

Bacillus pyocyaneus 114, 176 

Bacteremia 319 

Bacteria 135 

Bacterial infection 151 



INDEX 



413 



PAGE 

Bacterium coli 114 

proteus 114 

Bad complexion 172 

Bandage in affections of middle ear 206 

Barany's head-holder 91 

Beetles in ear 116 

Bezold's mastoiditis 167 

Bier's hyperemia 174 

Bilateral atresia 105 

congenital atresia 105 

with lateral vision 154 

mastoiditis 179 

Bites from dogs 113 

Bleeding from ear 365 

Blennorrhoeal secretions 185 

Blind deaf-mutes 254 

Blood coagula 118, 130, 214 

extravasations of tympanic mem- 
brane 164 

Bone-conduction 48, 105 

cranial, test of, by noises 80 

cranio-labyrinthine 48 

cranio-tympanic 48 

Bone formation in middle ear 108 

Bookbinding, deaf-mutes employed at.. . 250 

Bronchitis 165 

Bugs in ear 116 

Bulbus thrombosis 314 

venae jugularis 302 

Butterflies in ear 116 

Callous exostotic eminences 108 

Calomel, use of, in eczema 124 

Caloric excitability 237 

test in examination of semicircular 

canals 91 

Canalis chorda; 213 

Fallopii 212 

reuniens 241 

Capsule of labyrinth 222, 239 

tympanic cavity 239 

Carcinoma of auricular region 363 

Caries or necrosis of labyrinthine nucleus 

of petrous bone 258 

Cartilage conduction 48 

Cartilaginous necrosis 114 

Cataplasms, in treatment of middle-ear 

affections 174 

Catarrh of middle ear 373 

Catarrhal affections of middle ear 135 

etiology 135 

acute catarrh of tube 135 

acute catarrh of tympanum 136 

acute and subacute catarrh 136 

diagnosis 137 



PAGE 

Catarrhal affections of middle ear, acute 
and subacute catarrh, differen- 
tial diagnosis 137 

functional test 137 

otoscopic examination 136 

treatment 138 

chronic catarrh of middle ear 140 

prognosis 140 

treatment 140 

chronic exudative middle-ear catarrh. . 140 

diagnosis 141 

treatment 141 

chronic tubal catarrh 139 

prognosis and treatment 139 

subacute recurrent middle-ear catarrh. 142 

Catarrhus recens 136 

Catgut sutures in plastic operations of 

antrum 120 

Catheterization 61 

Cause of acquired deafness 361 

Cellular structure of nerve-end places 

of labyrinth 51 

Corti's membrane 51 

cupola *. . 51 

otolithic membrane 51 

Cerebellar abscess. .211, 273, 293, 329, 

330, 338, 353 

of metastatic origin 339 

mortality 354 

ataxia 350 

nystagmus 351 

Cheyne-Stokes respiration 351 

temperature of body 351 

tumor 352, 353 

vertigo 89 

Cerebral abscess 260 

manifestations capable of simulating 

meningitis 326 

Cerebrospinal fluid 268, 328 

meningitis 254, 386, 387 

Certain initial stages of acute infectious 

diseases 308 

Cerumen. 117 

Ceruminous embolus 117, 130 

Cherry-stones in ear 119 

Chills 172 

Chloroma 211 

Choice of occupation for deaf-mutes .... 251 
Cholesteatoma . . 109, 169, 180, 195, 220, 

348, 394 

of antrum 196, 200 

of attic 196, 200 

of hypotympanum 315 

of labyrinth 260 

of middle ear 191, 195 



414 



INDEX 



PAGE 

Cholesterin crystals in formation of epi- 
dermal balls 195 

test 197 

Chorda 213 

tympani 213, 215 

Chronic adhesive inflammation of middle 

ear 142 

diagnosis 143 

physical treatment 144 

prognosis and course 143 

treatment 144 

catarrh of middle ear 140 

eczema 125 

empyema 199 

exudative middle-ear catarrh 140 

myringitis ulcerosa 181 

osteitis 191 

of middle ear 213 

otorrhcea 181 

pulmonary tuberculosis 121 

purulent osteitis of middle ear 190 

suppurative mastoiditis 315 

osteitis 194 

ostitis of temporal bone 348 

tubal catarrh 139 

tuberculosis of labyrinth 258 

of middle ear 284 

ulceration of the external meatus 108 

Cicatrized tympanic membrane 110 

Circumcising the concha 108 

Circumscribed or diffuse necrosis 106 

and diffuse uncomplicated (simple) 

suppuration of labyrinth 265 

hemorrhages of labyrinth 365 

meningitis of posterior cranial 352 

pachyleptomeningitis 328 

suppuration of labyrinth 268, 381 

Circumvallate mastoid abscesses ...171, 175 

Cisterna perilymphatic vestibuli 259 

vestibuli 259 

Classes enf an tines for French deaf-mutes 248 

Cleansing external auditory duct 164 

pus focus 310 

Cleft palate 135 

Clinical examination of cerebrospinal 

fluid 356 

bacteriology 358 

chemical changes 358 

coagulation 358 

color 356 

cytology 358 

pressure • 356 

transparency 357 

Closing of persistent perforations of tym- 
panic membrane 186 



PAGE 

Coagulated milk particles entering tym- 
panic cavity 160 

Cochlear nerve 235 

Cold compresses in treatment of acute 

mastoiditis 174 

Collapse manifestations in acute infantile 

otitis 162 

Coma diabeticum 176 

Commercial arithmetic, instruction of 

deaf-mutes in 250 

Commissure of semicircular canal 224 

Communication of vestibularis with cere- 
bellum 54 

Complicated diffuse suppuration of laby- 
rinth 270 

tuberculous labyrinthitis 401 

Compresses in phlegmonous perichon- 
dritis 114 

Compression nystagmus 237 

Compulsory school attendance of deaf- 
mutes 248 

Concentric fistula 225 

Concha, diseases of the 99 

sixth auricular eminence of 11 

Concussion of lobe 132 

Conduction aphasia 342 

Congenital absence of scala of cochlea. . 224 

affections of static labyrinth 237 

anomalies of development of concha . . 99 

Darwin's point 99 

falciform appendages 101 

helix 99 

lobe 99 

Macacus point 99 

macrotia 99 

treatment 100 

microtia 101 

treatment 101 

of middle ear 242 

aplasia 239 

appendages 101 

atresia of external auditory canal .... 102 

of middle ear 242 

cholesteatoma of dura mater 195 

deafness 224, 234, 238 

hypoplasia of cochlearis 239 

of spiral ganglion 234 

labyrinthine partial deafness 238 

nystagmus 88 

tumors 195 

Connective-tissue atresia 110 

of middle ear 209 

layers 179 

Consanguineous marriages 239 

of degenerates 239 



INDEX 



415 



PAGE 

Constitutional ear diseases 366 

Construction of auditory duct 165 

Contents of external canal and tympanic 

cavity 55 

blood 55 

cerumen 55 

epidermal crusts 55 

pus 55 

Continuous heredity of otosclerosis 227 

Convulsions 171 

Co-procreative deafnes's, Hammer- 

schlag 238 

Corn in ear 119 

Corneal moisture 215 

Corti's organ 234 

Coryza 165 

Coughing . 159 

Course of temperature in otitic pyaemia 323 

Cranial abscess 293 

bone conduction, test of, by noises . . 80 

deformities 238 

Crepitant rales 60 

Cretinic aphasia 374 

deaf-mutism 373 

deafness 367 

dysacusis 370 

Cretinism 235, 367 

abnormal articulation in 371 

abnormal respiration in 371 

functional findings and functional 

tests in 371 

lingual and mental insufficiency in. . . . 371 

Cretins 222 

Crista vestibuli 260, 270 

Croupous inflammation of external mea- 
tus 108 

Crus cerebri 212 

Crustosum . . 121 

Crusts in affections of tympanic mem- 
brane 130 

in eczematous affections 121 

Crying in infantile otitis media 159 

out in middle-ear inflammation 162 

Cycloform, use of, in furunculosis 124 

ointment in treatment of traumatic 

pains 208 

Cyclopia 240 

Cymba conchse 115, 206 

Dark-red diaphany 280 

Daughter abscesses 349 

Deaf-mute child 225 

institutes 250 

instruction 254 

statistics 246 



PAGE 

Deaf-mutes, blind 254 

in Bavaria 253 

in Canada 249 

choice of occupation for 215 

compulsory education of 252 

kindergartens for 248 

living in Austria 253 

taught drawing 250 

in United States 249 

Deaf-mutism, acquired 254 

complicated by idiocy 243 

congenital 254 

five degrees of 77 

Deafness, dysthyral 368 

Deformity, acquired, of concha 106 

atresia 106 

cause of 106 

hsematoma auriculare 106 

inflammation 106 

piercing lobe for ear-rings 106 

serous perichondritis 106 

tuberculous perichondritis 106 

stenosis 106 

stricture 106 

treatment 106 

injections 106 

of membraneous cochlear canal 241 

Degeneration of Corti's organ 239 

of pars inferior 370 

of stria vesicularis 370 

Degenerative atrophy of auditory nerve 370 
of nerve-end places of labyrinth . . 

241, 373 

of octavus 373 

Delirium 172 

Delstanche's circular knife 202 

massage instrument 139 

Deltoid muscle 219 

Demarcated tumors 227 

Demonstration of unilateral deafness. ... 80 

alarm instruments 83 

Bezold's test 81 

Stenger's test 82 

test with hearing tube 81 

test with unweighted a'-fork 81 

Descending abscess 194 

within sternocleidomastoid 288 

abscesses of neck 276 

tuberculous abscess 392 

Descent of pus along tube 276 

toward submaxillary bone 276 

Destroyed faradic excitability 216 

Detritus in formation of epidermal balls 195 

Development of mastoid process 6 

Diabetes 121, 176, 207 



416 



INDEX 



PAGE 

Diagnostic value of lumbar puncture in 

otogenic affections 359 

Diet in empyema of labyrinth 269 

Difficulty of hearing 367 

Diffuse suppurative meningitis 275 

Digastric muscle 213 

Digastricus 219 

Diphtheria 159, 168 

Diplococci pneumoniae 114 

Diplococcus intracellular . 358 

serum 233 

Diploic abscess 277 

mastoid 169 

Direct drainage of bulbus 318 

rupture of tympanic membrane 128 

Displacement of cells of spiral ganglion 369 

Disturbance of coordination 297 

Disturbed sleep in acute infantile otitis 162 

Divergent strabismus 342 

Dorsal decubitus 174 

Double vision 351 

Drawing taught deaf-mutes 250 

Dry tampons of rice powder in furuncu- 

losis 124 

Ductus endolymphaticus 225 

Dura mater or sinus, exposure of 199 

Dysacusis 367 

Dysentery of nurslings 388 

Dysthyral deafness 368 

Ear affections in chronic infectious dis- 
eases 389 

in course of influenza 385 

in typhoid fever 382 

-speculum 125 

-spoon 117 

-worms 116 

Earache 155 

severe 156 

Ecoles professionelles 250 

Economics taught deaf-mutes 250 

Ectasia of membranous labyrinth 365 

Eczema madidans 121 

vesiculosum 121 

Education of deaf-mutes 246 

and provision for deaf-mute blind .... 254 

Eighth nerve of ear 46 

canalis ganglionaris 46 

central affections of cochlearis 47 

crus cerebri 47 

Deiters's nucleus 47 

geniculate ganglion 47 

hypoglossal nucleus 47 

inferior ganglia 46 

Munk's sensory sphere 47 



PAGE 

Eighth nerve of ear, nervus inter- 

medius 46 

nucleus accessorius 47 

parvicellularis vestibularis 47 

optic thalamus 47 

pons 47 

posterior corpus quadrigeminum.. . . 47 

radix of spinal acusticus 47 

spiral ganglia 46 

stria? acustieae 47 

substantia reticularis. 47 

superior ganglia 46 

tuberculum acusticum 47 

Electrical examination in peripheral pa- 
ralysis 216 

Elevation of temperature in mastoiditis. 171 

Embryonal epidermal germs 195 

Empty venous sinus 303 

Empyema of labyrinth 257 

Encephalitis 275 

Endemic constitutional deafness 368 

deafness 367 

Endocranial complications in middle-ear 

suppuration 190 

fistulae 225 

involvement 165, 167 

of mastoid process 172 

otitic affection 218 

otogenic affections 293 

Endolabyrinthal abscess 400 

Endolabyrinthitis 257 

Endotympanic measures 187 

End-to-end anastomosis 219 

England's deaf-mutes 252 

Entire program of instruction in deaf- 
mute institutes 255 

Epidermis, growth of 208 

Epileptoid movements of extremities. . . . 162 

Epithelial metaplasias 240 

Epitympanic suppuration 200 

Equilibrial disturbance 131, 267 

Equilibrium of the ktenophorae 51 

Erosion of capsule of labyrinth 199 

Erysipelas 123, 388 

of auricular region 173 

of concha 123 

Ethyl chloride, anaesthesia with 127 

Eustachian tube of middle ear 13 

Excentric fistula 225 

Excision of malleus and incus 202 

Exophthalmos 307 

Exostoses 125 

of lateral wall 222 

Exposure of dura 345 

and opening in thrombophlebitis 310 



INDEX 



417 



PAGE 

External auditory canal, anatomy of the 102 

fossa artieularis 102 

pars mastoidea 102 

rudimentary tympanum 102 

submaxillary articulation 102 

examination of the 55 

and tympanic membrane, normal 

otoscopic picture of . 56 

. meatus 99, 366 

ear . . . 9 

concha 9 

antihelix 9 

cymba conchae 9 

fossa navicularis 9 

external auditory meatus 9 

Arnold's nerve 9 

basal layer 10 

ceruminal glands 9 

fundus 9 

fundus of lateral half 9 

hairs 9 

median commissure 10 

membranous-cartilaginous part. . . 9 

normal papilla? 9 

osseous part 9 

Santorini's fissures 10 

sebaceous glands 9 

Extirpation of jugularis interna 318 

Extra- and intradural abscesses 352 

Extracranial affections of ear 276 

complications in middle-ear suppura- 
tion 190 

Extradural abscess 167, 260, 294 

abscesses 293 

initial 297 

latent 297 

manifest 297 

Exudative middle-ear catarrh. .135, 229, 402 

Facial and accessory nerves 220 

nerve 213, 269 

and hypoglossus nerve 219 

Family physician 410 

Faradic current in treatment of otoscle- 
rosis 233 

Fat crystals in epidermal balls 195 

Fenestra cochlea? 224 

vestibuli 224 

Fetal chondrodystrophy 369 

Fetid abscess 168 

secretion 207 

Fever 161 

Finding of tympanic membrane 153 

Finsen light in tuberculous perichondri- 
tis 392 



PAGE 

First kindergarten for deaf-mutes 248 

Fissura tympani squamosa 213 

Fissure of tegmen tympani 361 

Fistula? 199 

of antrum 295 

of endolabyrinth 224 

endolymphatic 225 

extradural 225 

intradural 225 

intravenous 225 

of labyrinth 224, 295 

concentric 225 

excentric 225 

extracranial 225 

submucous 225 

tympanic 225 

of mastoid 295 

paralymphatic 225 

perforating 225 

perilymphatic 225 

subperiosteal 225 

of tegmen 295 

Fistular symptom in mechanical reflex 

excitability 93 

Flaccid paralysis 221 

Fleas in ear 116 

Flies in ear 120 

Fluids entering tympanic cavity 160 

Follicular inflammation of auditory duct 125 

Folliculitis 125 

Foramen spurium 212 

canalis facialis 212 

stylomastoideum 212 

Foreign bodies in ear 116 

in external auditory duct 116 

diagnosis 118 

prognosis 118 

symptoms 117 

treatment 118 

Fork-pipe instrument of Rezold-Edel- 

mann 76 

Fossa helicis 115 

jugularis 224 

rhomboidea 212 

Fracture of temporal bone 361 

of upper wall of auditory canal 361 

Free respiration in affections of ear 376 

Froebel work, deaf-mutes trained in ... . 250 
Fulminating, diffuse suppurative men- 
ingitis 275 

Function of normal apparatus of semi- 
circular canals and vestibule 53 

Functional hearing test 64 

Fundus of eye 26S 

normal in pachymeningitis externa 297 



418 



INDEX 



PAGE 

Fundus of eye shows unilateral or 

bilateral venous plethora 328 

of osseous external auditory duct. . . . 203 

of tympanic cavity 193, 314 

Funnel test in tuberculous middle-ear 

suppuration 182 

Furunculin in treatment of eczema 125 

Furunculosis 124 

of scalp 173 

Gaertner's rhinometer 140 

Gait of deaf-mutes 244 

vestibule disturbance of 95 

Galvanic current in treatment of vertigo 265 

excitability 237 

insusceptibles 237 

test in examination of semicircular ap- 
paratus 92 

Ganglion sphenopalatinum 213 

Garlic particles in ear. 117 

Gaseous abscesses 168 

Gastro-intestinal and cerebral affections 159 

Gelle's bulb 131 

General physical unrest 172 

treatment in lupus 391 

tuning-fork tests 70 

Gelle's test 74 

negative result 74 

positive result 74 

Politzer's test 74 

Rinn6's test 72 

negative 72 

positive 72 

Schwabach's test 71 

in otitis media 72 

Weber's test 70 

Geniculate forceps 1 19 

ganglion 212 

Glandular abscesses and bundles 280 

Glioma 211, 353 

Glossopharyngeus , 213 

Goltz's sensory organ 52 

Gram-positive cocci 358 

Granulation-polypus 201 

Granulation of pharyngeal tube 394 

and polypi 199 

Granulomata 126 

Growth of epidermis 208 

Gutta-percha cast in atresia of external 

auditory meatus 108 

Gumma 353 

Hsematogenous infection 159 

Hsematoma Ill 

auriculare Ill 



Haematotympanum 365 

Hair-pins, cause of rupture of tympanic 

membrane : 128 

use of, may lead to serious suppuration 

of middle ear 117 

Harmonica of Urbantschitsch 76 

use of, in monaural hearing test 244 

Hartmann's auxiliary schools for deaf- 
mutes 256 

Healthy tympanic cavity germ-free. . . . 161 
Hearing capacity of animals without lab- 
yrinths 49 

distance for Politzer's acoumeter 69 

exercises for deaf-mutes 255 

test by speech, importance of 65 

by whispering 69 

Helmholtz's theory of resonance 49 

Hemorrhage of ear 365 

of labyrinth 51, 269 

Hemorrhagic labyrinthitis 365 

otitis 366 

Hereditary constitutional affections 159 

degenerative deaf-mutism, Hammer- 

schlag 234 

difficulty of hearing 227 

syphilis 234 

syphilitic diseases of middle ear 402 

Herpes 123 

Hirschberg's electromagnet 120 

Hollow foci of spongiose bones 288 

Homes in Austria for deaf-mutes 253 

Horizontal nystagmus 86 

Horticulture taught deaf-mutes 250 

Hot-air treatment in lupus 391 

How to test by speech 68 

Hutchinson's teeth 404 

Hydrocephalus internus 331 

Hygienic precautions in treatment of 

deafness 254 

rules concerning ear 376 

Hypaesthesia of external duct 128 

Hyperemia 133, 153, 229, 235 

of ear 366 

Hypoplasia of cochlear nerve 239 

Hypothyroid cretins 368 

Hypothyroids 368 

Ichorous bulbus thrombosis 286 

Icterus 172 

Idiopathic atrophy of auditory nerve . . . 238 

Impaired hearing during school life 407 

Imperial ministry for education, deaf- 
mute institutes subordinate to, in Aus- 
tria 253 

Importance of hearing test by speech ... 65 



INDEX 



419. 



PAGE 

Inability to stand on one leg with closed 

eyes 267 

Increased vascularization of tympanic 

cavity 229 

Indirect rupture of tympanic membrane. 129 

course 131 

diagnosis 131 

examination 130 

functional test 131 

otoscopic findings 130 

symptoms 129 

treatment 131 

Infantile otitis .■ 161 

Infectious neuritis of eighth nerve 385 

suppurative meningitis 325 

Inflammation, acute 211 

of lymph-vessels 174 

of mastoid process 172 

of mastoid to squama and zygomatic 

process 167 

of middle ear 163 

Inflammatory affections of labyrinth . . . 256 

ankylosis 173 

infections of tympanic membrane .... 132 

acute inflammations 132 

course 133 

diagnosis 133 

etiology and occurrence 132 

symptoms 133 

treatment 134 

subacute and chronic inflammation. 134 

course 134 

diagnosis - r 134 

treatment 134 

otogenic paralysis of facial nerve 216 

paralysis 262 

of nerve 214 

thrombosis 304 

Influenza bacillus 146, 168, 385 

myringitis 385 

otitis 164, 385 

Instruction and training of all deaf-mutes 249 

Insufflation 60 

of mycodermin 127 

Insulated thrombophlebitis 306 

Internal administration of iodine and 

phosphorus 238 

auditory canal 212, 224 

ear 34 

membranous labyrinth 34 

cortical membrane 38 

cresta ampullares, histological 

structure of 38 

external wall 41 

ligamentum spirale 41 



PAGE 

Internal ear, membranous labyrinth, 

prominentia spiralis 41 

sulcus spiralis cxternus. ........ 41 

vascular stria 41 

hair-cells 36 

hair-processes of macula utriculi. 37 

arrangement of 38 

macula sacculi 37 

macula of vestibular sacs 38 

membrana basilaris 39 

Bottcher's cells 39 

cells of Claudius 39 

crista spiralis 39 

Deiters's prop-cells 39 

Hensen's arch 39 

high cylindrical epithelium ... 39 

lamina propria 39 

membrana reticularis 40 

spiral ligament 39 

sulcus spiralis internus 39 

nerve-end cells of labyrinth 38 

nerve-end fibres 38 

nerve terminations of the 35 

crista ampullaris inferior 36 

crista ampullaris lateralis 36 

crista ampullaris superior 36 

macula basilaris cochleae 36 

macula sacculi 36 

macula utriculi 36 

osseous cochlea 43 

helicotrema 44 

lamina spiralis ossea primaria. . 44 

lamina spiralis ossea secundaria 44 

modiolus 43 

Rosenthal's duct 44 

scala tympani 44 

scala vestibuli 44 

tractus spiralis foraminosus. ... 44 

osseous labyrinth 41 

osseous semicircular canals 43 

otoliths 37 

papilla basilaris cochleae 38 

lamina spiralis ossea 39 

membrana basilaris 39 

membrana vestibularis 39 

peripheral wall 39 

scala media. " 39 

pars inferior 34 

caecum cupulare 35 

caecum vestibulare 35 

canalis utriculo-saccularis 34 

ductus endolymphatic^ 34 

ductus reuniens 35 

maculi sacculi 35 

membranous cochlear duct .... 34 



420 



INDEX 



PAGE 

Internal ear, membranous labyrinth, 
pars inferior, papilla basilaris 

cochleae 35 

saccus endolymphaticus 34 

sulcus 34 

pars superior 34 

ampulla inferior 34 

ampulla lateralis 34 

ampulla superior 34 

ampullae 34 

crista ampullaris inferior 34 

crista ampullaris lateralis 34 

crista ampullaris superior 34 

cristse ampullares 34 

inferior sinus 34 

macula utriculi 34 

semicircular canals 34 

sinus utriculi anterior 34 

superior sinus 34 

utricle 34 

perilymphatic tissue 41 

area cribrosa sacculi 42 

crista vestibuli 42 

recessus ellipticus 42 

recessus sphaericus 42 

utriculoampullar nerve 42 

vestibule 42 

perilymphatic vestibular cistern. ... 38 

prop-cells 37 

recessus utriculi 38 

sinus utricularis anterior 38 

topography of nerve-end place of 

labyrinth 44 

topography of the 45 

cochlear canals 45 

eminentia arcuata 45, 46 

fossa subarcuata 45 

perilymphatic canals 45 

porus acusticus internus 45 

vestibular cistern 45 

upper wall of cochlear duct 41 

Interstitial keratitis 404 

Intertrigo 121 

Intestinal tract 163 

Intradural abscess 330 

Intrameningeal abscess 327, 330 

Involuntary twitching in paralysis of 

facial nerve 216 

Involvement of mastoid process 163 

Iodoform in treatment of middle-ear af- 
fections 177, 193 

Iridocyclitis 215 

Irrigation in treatment of chronic middle- 
ear suppuration 184 



Isoform in treatment of middle-ear af- 
fections 177 

Italian deaf-mutes 252 

Itching of skin 122 

Jugularis interna 302 

Keller, Helen, of Boston 254 

Keloid tumors ... 106 

Keratitis 215 

Kindergarten and preparatory schools 

for deaf-mutes 248 

Koch's tubercle bacillus 389 

Koerner's plastic operation of auditory 

duct 210 

or Sibenmann's plastic operation Ill 

Kuemmel's symptom of pressure varia- 
tion 93 

Kugel's test 131 

Labyrinth 194 

acoustic 245 

fistula? 226 

operation 271 

static 245 

Labyrinthal fistulae 400 

Labyrinthine nystagmus 86, 87 

vertigo 88, 89, 131, 226 

Labyrinthitis 218 

serosa ' . . . . 264 

Labyrinthogenic cerebellar abscesses. . . . 275 

extradural abscesses 273 

meningitis 335 

paralysis of facial nerve 271 

Lachrymation . 215 

Lactic acid in tuberculous perichondri- 
tis 392 

Lagaena 52 

Lagophthalmos 162, 215, 326 

Lamina spiralis 260, 270 

Larvae in ear 120 

Lassitude 172 

Late teething 155 

Lateral knee 212 

ossicles 192 

semicircular canal 222 

Lead-pencils in ear 128 

Leontiasis ossea 238 

Leukaemia 211 

Levator veli palati 213 

Levulose, application of, in eczema 125 

Lids, eczema of 121 

Ligation of jugular 316, 317 



INDEX 



421 



PAGE 

Light massage in serous perichondritis 114 

reflex in otoscopy of tympanic cavity . 57 

-cone 57 

-sector 57 

-spot 57 

Lime deposits in bone 229 

in manubrium 181 

Lingual nerve 213 

Lip-reading 244 

and articulation ' 255 

Living larvae of flies in ear 117 

Local anaesthesia of ear 97 

in fistula; '. 284 

changes in otogenic pyaemia . . 324 

injection anaesthesia 208 

Localized headache 172 

Locksmith work, deaf-mutes instructed 

in 250 

Loss of motility of neck and head 215 

Lucae's pressure sound 146 

Lucilia macellaria in ear 116 

Luetic endarteritis . - 403 

Lumbar puncture 274 

in cerebral abscess 340 

and its significance in otology 355 

Lupus 123 

of concha 390 

crustosus 390 

erythematodes 390 

exfoliations 390 

exulcerans 390 

maculoeus 390 

tuberosus 390 

vulgaris 390 

Lymph vesselsof occipital portion of scalp 26 

Lymphocytes in tuberculous meningitis. 358 

Lymphocytosis 358 

Lymphoid tumefaction 366 

Lymphomatoses 211 

Lymphomatosis 366 

Lymphomatous ear diseases 365 

Lymphosarcoma 211, 364 

Lysis 152 

Macula lagaense 52 

Madidans 121 

Malaria 308, 309 

Malignant new-formations of ear 363 

tumors of middle ear 211 

Malleus and incus 192 

excision of 202 

Marasmus 121 

Masseter 213 

Mast-cells 135 

Mastication and drinking 215 



PAGE 

Mastoid abscess 168, 169, 287 

operation 319 

process, development of 6 

of middle ear 29 

triangle 204 

Mastoiditis 169, 194 

method of operation in 176 

operative interference in 175 

Mastoidotomy 176 

Matches in ear 128 

Measles 152, 168 

Medium hearing ability 373 

Medullary sarcoma of the dura 283 

Membrana tectoria 240 

Membranous canal of cochlea 235 

labyrinth of internal ear 34 

occlusion of middle-ear spaces 209 

tubal septum 209 

Meningism 162, 165 

Meningismus . . . . : 326 

Meningitic foci 329 

labyrinthitis 387 

deafness _ 386 

panotitis of scarlet fever or measles 

type 387 

suppuration of labyrinth 256, 387 

symptoms 162 

Meningitis 293, 333 

Meningoencephalitis 314 

Metastases in the bones 320 

joints 320 

muscles 320 

Metastasis 257 

Metastatic coxitis 321, 323 

thrombosis 305 

Methods of cleansing external canal and 

tympanic cavity 56 

ear-pincettes 56 

Hartmann's attic cannula 56 

of examining middle ear 59 

auscultation 59 

auscultation tube 59 

Siegle's otoscope 59 • 

Valsalva test 59 

of testing vestibular apparatus 93 

counter-rolling of eyes 94 

equilibrium of body 93 

goniometer test '. 94 

Romberg's method 93 

vestibular equilibrium 93 

Michel's clamps 177 

Micro-organisms 195 

Middle ear 13 

deep cervical lymph glands 25 

empyema 163 



422 



INDEX 



PAGE 

Middle ear, Eustachian tube , . . . . 14 

hard palate 14 

isthmus tuba? 13 

muscular tensor veli palati 13 

ostium pharyngeum tuba? 13 

tympanicum 13 

pterygoid process 13 

Rosenmuller's fossa 13 

tympanic mucosa 13 

examination of 55 

inflammation of 256 

lymph vessels of the 25 

mastoid process 29 

antrum triangle 29 

auditory meatus 29 

crista temporalis inferior 30 

diploic mastoid 32 

flat mastoid 32 

foramen stylomastoideum 30 

incisura mastoidea 33 

large, bullous mastoid 32 

mastoid triangle 29 

mixed mastoid 32 

normal mastoid 32 

osteoporosis 32 

osteosclerosis 32 

pneumatic mastoid 32 

pointed mastoid 32 

small mastoid 33 

sternocleidomastoid 29 

suprameatal spina 30 

planum mastoideum 26 

carotid plexus 26 

geniculate ganglion 26 

glossopharyngeus 26 

otic ganglion 26 

plexus tympanicus 26 

tympanic nerve (Jacobson's) 26 

retropharyngeal glands 25 

spaces 105 

submaxillary glands 25 

suppuration 169 

topography of the 26 

memhrana flaccida 27 

Prussak's space 27 

Shrapnell's membrane 26 

tuberculosis 396 

tympanic antrum 28 

fossa incudis 28 

posterior auditory canals 28 

superior auditory canals 28 

tegmen antri 28 

tympanum 15 

aditus ad antrum 16 

bulbus jugularis 15 



Middle ear, tympani 16 

columella 18 

diaphysis 18 

epiphysis 18 

epitympanum 17 

external malleus ligament 22 

first postoral arch 20 

fossa jugularis 15 

fossula fenestras cochlae 17 

fundus of tympanic cavity. ... 15, 16 

Helmholtz's process 17 

hypotvmpanum 17 

incisura Rivini 17 

incus IS 

long crus. 18 

ossiculum Sylvii 18 

internal carotid 25 

malleus ligament 22 

maxillary artery 25 

labyrinthine wall 16 

lamina propria 20 

lateral wall of tympanic cavity. . . 17 

malleus 18 

head 18 

manubrium 18 

neck 18 

Meckel's cartilage 20 

medial wall of tympanic cavity ... 18 

median cranial fossa 16 

mesotympanum 17 

middle meningeal artery 25 

mucous membrane 22 

anterior malleus fold 23 

fold of chorda 23 

fossula fenestra? vestibuli 23 

malleus-incus articulation 22 

malleus-incus fold 22 

posterior malleus fold 23 

stapes fold 23 

musculo-tubal canal 16, 22 

osseous tube 16 

paries tegminis 16 

pes anserinus 20 

posterior auricular 25 

processus cochleariformis 17, 22 

-pyramidal process 22 

s. Fallopia? 17 

second postoral arch. 20 

inferior epihyal bone 20 

pedicular process 20 

stylo-hyoid ligament 20 

stapedius muscle 17 

stapes IS 

crura IS 

head 18 



INDEX 



423 



PAGE 

Middle ear, mastoid process, stapes, 

plate 18 

stapes muscle 22 

stratum circulare 20 

radiatum 20 

stylomastoid artery 25 

sulcus tympanicus s. Jacobsonii . . 17 

syndesmosis 20 

tympanic membrane 20 

pars flaccida 20 

pars tensa 20 

substantia propria 21 

umbo 20 

tympanosquamous fissure IS 

tegmen tympani 16 

Mimic musculature , 214 

Moist eczema 165, 173 

Moisture in eczema 121 

Monaural test with hand-organ 244 

Monochord, use of, to determine highest 

tone limit 76 

Mononuclear leucocytes 135 

Mortality of otogenic pyaemia 324 

Motility of tubal musculature 135 

Modelling, deaf-mutes instructed in ... . 250 

Modiolus 260, 270 

Morbillous otitis 376, 384 

Mucor mucedo in ear 116 

Mucous membrane 235 

Mud baths to ear 233 

Multiple cicatrices 187 

tuberculosis of cranial bones 282 

Musca macellaria in ear 116 

Muscular contracture 217 

Mycodermin, application of, in eczema. . 125 

Mydriasis 342 

Myringitis acuta 149 

chronica ulcerosa 134 

hemorrhagica 385 

Myxomatous polyps 180 

Nasal respiration 162 

tuberculosis 135 

Nasopharyngeal changes in cretinism . . . 371 

Nausea 262 

Needlework for deaf-mute women 250 

Nerve, auditory 212 

-ending of labyrinth : 370 

facial 212 

-ganglia 235, 239 

-sheaths 214 

-trunk 219 

Nerves, accessory 219 

hypoglossus 219 

trigeminal 212 



PAGE 

Nervus accessorius. 302 

anastomoticus 213 

auricularis posterior 213 

intermedius 212 

marginalis mandibular 213 

petrosus superficialis major 213 

stapedius 213 

utriculo-ampullaris 212 

Vidianus ' 213 

Neurasthenia of labyrinth 269 

Neurilemma 219 

Neuritis of abducens nerve 385 

_ acustico-facialis 211 

facial nerve 385 

of trigeminus nerve 385 

Neurolabyrinthitis 269, 375, 385 

Neurotic or neurasthenic nystagmus. ... 88 

New-formation of cortex 178 

Non-diagnosed metastases 325 

Normal hearing distance 65 

Novocaine in anaesthesia of ear 98 

and alypin in anaesthesia of ear 97 

Number of deaf-mutes in world 246 

of deaf-mute institutions 247 

pupils instructed annually 247 

Nystagmus 261, 266 

congenital 88 

horizontal 86, 90 

labyrinthine 86, 87 

neurotic 88 

oblique 87 

optical 88 

rotating. 90 

spontaneous 86, 87 

vertical 86 

Objective vertigo S8 

Oblique nystagmus 86 

Obliteration of window of labyrinth .... 222 

Obstinate eczema of concha 366 

Obturating or occluding thrombosis 304, 314 

Occipital muscle 213 

Occiput , . . 174 

Occlusion of cochlear window 222 

Occupation for deaf-mutes, choice of . . . 215 

Ocular fundus 351 

(Edema , 133, 153, 349 

and hypersemia of mucosa of middle ear 136 

Olecranon 121 

Opening antrum, antrotomy 177 

Operative exposure of middle-ear spaces 202 

interference in sarcoma of ear 364 

trauma 205 

Opisthotonos 351 

Optic aphasia 342 



4^24 



INDEX 



PAGE 

Optical nystagmus 88 

Origanum, use of, in removing articles 

from ear 120 

Orthopaedist 408 

Osmosis 137, 229 

Osseous atresia 191 

capsule 235 

external auditory canal 11 

os tympanum 11 

fistula; 193 

fundus of tympanic cavity 203 

trabecular of hypotympanum 194 

Ossiculectomy 202 

Osteitic osseous foci 242 

Osteitis 191 

vasculosa 229 

Osteomyelitic abscess 321 

Osteomyelitis 389 

of cervical vertebrae 290 

Osteoperiostitis 168, 389 

Osteophytes 190 

formation of 109 

Osteoplastic 312 

Osteoporosis of mastoid process 32 

Osteosclerosis 190 

mastoid process 32 

Otitic abscesses of temporal lobe 211 

descending abscesses 308 

of neck 287 

form of suppuration of labyrinth 256 

meningitis 360 

or cerebral abscess 308 

pyaemia 319 

abdominal form 320 

cranial form 320 

thoracic form 320 

serous meningitis 325 

sinus phlebitis 301 

thrombophlebitis 293, 301, 306 

thrombosis of sinus cavernosus 304 

tuberculosis 389 

Otitis externa eczematosa 121 

diagnosis 122 

symptoms 121 

treatment 123 

follicularis 125 

course 126 

diagnosis 126 

examination 126 

symptoms 125 

treatment 125 

furunculosa 155, 173 

runs a febrile course 155 

haemorrhagica. .- 385 

media acuta simplex 149 



PAGE 

Otitis media acuta simplex of nursing 

period 159 

Otogenic abscess 342 

of left temporal lobe 338 

of temporosphenoid lobe 337 

cerebellar abscesses 347 

paralysis of facial nerve 211 

pyaemia 310 

tuberculous meningitis 335 

Otolithic apparatus of crabs 51 

Otoliths 240 

Otomycosis 118 

Otorrhcea 171 

Otosclerosis 138, 227, 406 

bathing in treatment of 232 

high altitudes in treatment of 232 

medication 232 

phosphorus in treatment of 232 

phytin in treatment of 232 

pilocarpinum hydrochloricum in treat- 
ment of 232 

pneumomassage in treatment of 232 

sea air in treatment of 232 

secondary psychic manifestations in . . 231 

simulates secretory catarrh 231 

thyroidin treatment of 232 

transitory forms 231 

X-ray treatment of 233 

Otoscopic examination of auditory canal 55 

ear-speculum 55 

reflector 55 

and findings 164 

Overexcitability 237 

Oxycephalia 238 

Pachyleptomeningitis 273, 299 

Pachymeningitis 199 

externa 167, 260, 273 

haemorrhagica 358 

Painful pressure point at tragus 173 

swelling of mastoid glands 174 

Painless hyperaemia 117 

Panophthalmia 215 

Panotitis 375, 385 

Panse's plastic operation 205 

Papilla basilaris cochleae 48 

Papules 121 

Papulosum 121 

Paracentesis 138, 151, 156 

in anaesthesia^ of ear 97 

in catarrhal or inflammatory changes 

of nose 384 

technical instructions to be observed in 151 

Paracusis Willisii 230 

Paralabyrinthine abscess 294 



INDEX 



425 



PAGE 

Paralabyrinthitis 259 

Paralyses of facial nerve.. . 199, 211, 214, 400 

Paralysis, faradic treatment for 218 

of frontal branch 215 

galvanic current, use of, in 218 

hot-air baths in 221 

hot-air treatment in 218 

inducement of perspiration in . 221 

inflammatory 211 

laxatives in 218 

light massage of facial muscles in 218 

massage in 221 

mimic exercises in 218 

perspiration in 218 

postoperative course in 220 

of sphincter of lid 215 

of stapedius nerve 215 

of superficial petrous nerve 215 

traumatic 211 

of velum palatum 135, 215 

Paraphasia 342 

Parenchymatous keratitis 404 

Parietal thrombi 313 

thrombosis 304, 311 

Parotid labyrinthitis 382 

plexus 215 

sarcoma 364 

Partial or complete deafness . . . 117, 194, 256 

Passow's method 210 

Pathological ligaments 190 

osseous foci 241, 383 

Pebbles in ear 119 

Pediculosis capitis 174 

with lymphangitis of the scalp 173 

Peduncles of flowers or plants 128 

Pedunculated flaps 108 

Pelotes in pachymeningitis 301 

Pen-holders in ear 128 

Perforating abscess 276 

Perforation of abscess 167, 340 

to external auditory canal 276 

involving endocranium 109 

of Shrapnell's membrane 200 

Perichondritic corrugation of the concha 107 

Perilabyrinthitis 257, 259 

Periodical lesions of oral and ocular 

branches 216 

Periostitis of capsule 229 

Peripheral otogenic paralysis 213 

paralysis 216 

Perisinous abscess 306, 386 

Peritonsillar abscesses 287 

Permanent antrum fistula 178 

Pertussis 159, 388 

Pes anserinus 57 



PAGE 

Petrosus inferior 315 

Petrous bone 212 

Pharyngeal tumor 135 

Phenomenon of floating sounds 49 

Phlegmonous perichondritis 114, 392 

treatment 114 

Physiological stimulation for nerve ter- 
minations 51 

molecular motion 51 

oscillation 51 

percussion 51 

vibration 51 

waves 51 

Physiology of ear 48 

of sound-conducting apparatus 49 

of static labyrinth 51 

Pirquet reaction in tuberculous middle- 
ear suppuration 396 

Planum mastoideum 176 

Plastic operation 219 

support 204 

Platysma 213 

Plethoric diploic bone of pars mastoidea 163 

Plexus parotideus 213 

Pneumococcus 161 

infection 179 

Pneumomassage 146 

Pneumonia 308 

Polynuclear and large mononuclear leu- 
cocytes in suppurative cerebrospinal 

meningitis 358 

Polyp formation 169 

Polypi 197 

removal of • 183 

Pons cerebelli 214 

Popliteal space 121 

Positive puncture reaction in tubercu- 
lous middle-ear suppuration 396 

Romberg's symptom 267 

Postoperative paralysis of facial nerve. . 214 

prognosis of otogenic pyaemia 324 

Preparation for paracentesis 156 

Presence of thrombus 313 

Preserved faradic excitability 216 

Pressure atrophy 214 

necrosis 112 

Prevalence of deaf-mutism 246 

Preventing pus from entering blood cur- 
rent in thrombophlebitis 310 

Primary cholesteatoma 195 

and secondary cholesteatomata 195 

Printing, deaf-mutes instructed in 250 

Prognosis of cuts 113 

Progressive partial deafness 237 

Projectiles in ear. 120 



426 



INDEX 



PAGE 

Promontorial shadow in diagnosis of in- 
ternal-ear affections 235 

Protheses in deformity of concha 102 

in pachymeningitis 301 

Provision for deaf-mutes by public char- 
ity or government help 252 

Pseudoleuka?mia 211 

Psychic aphasia 374 

deafness 372 

Psycho-physiological significance of sta- 
tolithic apparatus 54 

Pterygoid muscles 213 

Ptosis : 342 

Punctiform hemorrhages of external au- 
ditory meatus 388 

Purulent mastoiditis 179 

meningitis 211 

osteitis 193 

media 132, 149 

treatment 150 

of middle ear 199 

perichondritis 114 

periphlebitis 286 

pharyngitis 286 

Pus in submucous tympanic fistulse 226 

focus in mastoid 314 

Pyaemia or sepsis 324 

Pysemic metastasis p 319 

sinus thrombosis 354 

symptoms in pneumonia 309 

Pyorrhoea of tube 394 

Qualitative determination of hearing. . . . 244 

test of hearing by tuning-fork 75 

Quantitative determination of hearing. . 243 

test of hearing by tuning-fork 79 

Bezold-Edelmann graded sound se- 
ries 79 

Gradenigo forks 79 

Kittlitz-Bernd fork 79 

measurement of difference of per- 
ception '. 79 

Radical operation after Kuester-Berg- 

mann 204 

after Stacke 203 

after Zaufal 203 

Radium, use of, in sarcoma of ear 364 

Rami temporales 213 

zygomatici 213 

Rapid marasmus 176 

Rarefied air in middle-ear affections .... 145 

Reactive sclerosis 190 

Recesses in labyrinth 224 

Recessus ellipticus 259 



PAGE 

Recessus utriculi 212 

Recumbent position of nurslings 160 

Reduced hearing acuity 371 

Regeneration of osseous trabecula 178 

Regional pain 172 

Reliable drainage in thrombophlebitis . . 310 

Removal of granulations 183 

Repeated vomiting 267 

Resection of mastoid indicated 174 

Respiratory tract 163 

Retro-auricular cutaneous incision 120 

lymph-glands 388 

Reversed monaural stethoscope 114 

Rhachitic children 222 

Rhachitis 121 

Rheumatic paralysis -216 

Rhinoscleroma 135 

Ringing in ear 262 

Romberg-Erben's test in tabetic vertigo 90 

Rosenmuller's fossa 162 

Rotatory chair 90 

Round facial nerve bundle 212 

Rubeola 388 

Rupture of tympanic membrane 388 

Sabre cuts 112 

Sacculo-cochlear degeneration 240 

type 240 

Sacculus 259 

Saccus empyema 273 

Sagittal semicircular canal 224 

Sarcoma 353 

of ear 364 

of external auditory meatus 109 

Sarcomatous mixed tumor 364 

Scabs 187 

Scala 260 

tympani 228 

Scales 121 

Scarlatinal otitis 376 

Scarlet fever 152, 159, 168 

School otologist 407, 408 

Schools for advanced education : . 250 

Sclerosis of connective tissue. . . . .• 278 

Scrofulosis 207 

Second trigeminus branch 213 

Secondary atrophy of nerve-ganglia. . . . 239 

cholesteatoma 195 

sound manifestations 49 

Secretion 207 

Secretory middle-ear catarrh 136 

Self-induced rupture of tympanic mem- 
brane 128 

Semicanalis nervi Vidiani 213 

Semicircular canals 259 



INDEX 



427 



PAGE 

Semicircular canals, examination of ... . 90 

functional examination of 86 

Sense of hearing in new-born 50 

Septum 20S 

Sequestration of labyrinth 400 

of petrous bone 258 

Serous labyrinthitis 264, 269, 384 

meningitis 293 

osmosis 229, 349 

perichondritis . 113 

diagnosis 113 

symptoms 113 

treatment 113 

Shoemaking, deaf-mutes instructed in : . 250 

Siegle's funnel 131 

Sign language to converse with each other 256 

Silk or silver wire suture 221 

Silver nitrate and ear-baths 124 

Simple otitis media 149 

resection of mastoid 176 

rhinitis 180 

Simulate suppuration of accessory nasal 

cavities or of sphenoid bones 192 

Simulated bilateral deafness, demonstra- 
tion of 84 

hearing insufficiency, demonstration of 83 
unilateral deafness, demonstration of 83 
Single-entry book-keeping, deaf-mutes 

taught 250 

Sinus sigmokleus 302 

thrombosis 199, 206, 293, 301, 329 

Skin fistula of jugular 316, 317 

Skull conduction of sound 49 

Sleeplessness 162 

Small winged insects in ear 116 

Sneezing 159 

Sound-conduction 117 

-islands 231 

-perceptions in new-born 50 

Speech, test arrangement for 66 

Spindle-cell sarcoma 364 

Spiral ganglion 239 

Spongiosis of labyrinth capsule 228 

Spontaneous healing of thrombophlebitis 310 

labyrinthine nystagmus 87 

nystagmus 86, 209, 131 

Squamosum 121 

Staggering in vertigo 267 

Stapes ankylosis 222, 228 

Staphylococci 114, 274, 358 

Staphylococcus 168 

meningitis 335 

pyogenes aureus 146 

Stasis 299 

Static labyrinth 48, 52 



PAGE 

Static perceptions emanating from 52 

organ (Breuer) 48 

Statocyst 245 

Stenosis of auditory duct 169 

Sterile borvaseline, use of, in inflamma- 
tion of concha 115 

wick 177 

Sternocleidomastoid muscle 207 

Stern's sound variator 76 

Straws in ear 128 

Streptococci 114, 274 

Streptococcus 146, 168 

infection 179 

mucosus 165, 168, 176, 385 

pyogenes 176, 385 

Stria vascularis 234 

Stupor 162, 351 

Stylohyoideus muscle 213 

Stylomastoid foramen 213 

Subacute leukaemia 364 

Subarachnoid abscesses 328 

Subcortical sensory aphasia, symptoma- 
tology of 77 

Subjective noises 236, 262 

symptoms 182 

Submucous tympanic fistulae 226 

Suboccipital suppurations 352 

Subperiosteal abscess 179, 277, 281, 394 

gas abscesses 278 

mastoid abscess 276 

Sudden unrest 162 

Sulcus endolymphaticus 225 

Superficial cerebral oedema 331 

encephalitis 331 

osseous erosions 222 

Suppuration of labyrinth 190, 329, 352 

Suppurative catarrh of middle ear 21 

gummata in region of squama of tem- 
poral bone or zygomatic process . 282 

inflammation 273 

of labyrinth 257 

acute 257 

chronic 257 

circumscribed 257 

diffuse 257 

infectious 257 

subacute 257 

of static labyrinth 266 

labyrinthitis 261, 375 

acute 261 

chronic 261 

diffuse 261 

meningitis 165, 1S3, 218, 260 

metastases in bones 321 

ostitis ' 217 



428 



INDEX 



PAGE 

Suppurative otitis media.. 105, 118, 366, 382 

cerebral and general symptoms. . 333 

free paracentesis in 332 

Kernig's symptom in 333 

of petrous bone 328 

paralabyrinthitis 226 

perichondritis 205 

periphlebitis 303 

sinus phlebitis 273 

typhoid otitis 384 

Surgical drainage of bulbus 315 

exposure and opening of bulbus 315 

forms of chronic middle-ear suppura- 
tion 190 

Survey of acoustic and static tests 96 

Galton-pipe test 96 

Stenger's test 96 

Sweden, special law in, for instruction of 

deaf-mutes 249 

Swelling of faucial tonsils 155 

of skin , . 174 

Symptom-complex of serous labyrinthi- 
tis 381 

Symptom of exudative middle-ear ca- 
tarrh 136 

Symptomic peculiarities in infantile 

otitis 161 

Symptoms of atresia in external auditory 

meatus 110 

equilibrial disturbance 110 

evacuation of pus through Eustach- 
ian tube 110 

headache 110 

regional pains 110 

rotatory vertigo 110 

spontaneous nystagmus 110 

vomiting 110 

and course of metastases 321 

Syncephaly 104 

Synchondrosis 6 

Synechia; 132, 181, 187 

Synotia 104, 222 

Syphilis 113, 135 

of labyrinth 269 

Syphilitic affections of ear 401 

roseola of concha 401 

Syringing contraindicated 119 

Systematic instruction in gesticulation 

given to deaf-mutes 255 

Tabes mesenterica 163 

Tabetic vertigo 89 

Tailoring, deaf-mutes instructed in 250 

Talcum, use of, in eczema 124 

Tampons in plastic surgery 120 



Temperature curve in otitic thrombo- 
phlebitis 307 

Temporal bone 194 

of ear, anatomy of 1 

antrum 5 

apertura externa aquseductus ves- 

tibuli • 3 

area cribrosa 3 

carotid canal 4 

cerebellar surface 2 

cerebral surface 2 

circular commissure 7 

cochlear aqueduct 7 

cochlear duct and saccule 3 

Eustachian tube 1, 5 

facial nerve 3 

fenestra cochleae 5 

fissura squamomastoidea 6 

flocculus cerebelli 2 

fossa subarcuata 2 

fossula petrosa 5 

fundus of internal auditory canal 3 

fundus of tympanic cavity 8 

hiatus spurius 7 

impressiones digit atae 1, 7 

inferior ampullar nerve 3 

inferior maxilla 1 

internal auditory meatus 3 

internal meatus 3 

intramastoid fissure 6 

jugular fossa 4, 6 

mandibular fossa 1 

middle meningeal artery 1 

osseous crest * 3 

osseous septum 6 

parietal bone 1 

petrosquamous fissure 1 

petrosquamous sinus 7 

petrous pyramid 6 

processus cochleariformis 5 

promontory 5 

sagittal semicircular canal 7 

sigmoid sinus 18 

sigmoid sulcus 3 

soft palate 5 

squamous part 1 

stapedius muscle 5 

stylomastoid foramen 5 

sulcus arterial meningeal 8 

sulcus petrosquamosus 7 

sulcus petrosus 8 

sulcus petrosus inferior 7 

sulcus petrosus superior 7 

superficial hiatus spurius 3 

superior macula cribrosa 3 



INDEX 



429 



PAGE 

Temporal bone of ear, tenso-tympani 

muscle 1' 

tensor tympani muscle 5 

tractus spiralis foraminosus 3 

trigeminal ganglion 3 

tuberculum supramastoideum .... 8 

tympanic groove 5 

tympanic membrane 1 

tympanic ring 1, 6 

tympanosquamous fissure 6 

tympanum 1 

upper osseous semicircular canal.. 2 

upper semicircular canal 7 

vestibular aqueduct 3 

vestibular window 5 

with persistent squamomastoid 

fissure 31 

zygomatic process 1 

Tendon of sternocleidomastoid 177 

Tenotomy of tensor tendon 146 

Test arrangement for speech 66 

binaural test 66 

computation 67 

field of computation 67 

by speech, how to 68 

medial hearing distance 67 

method 67 

monaural test 67 

of cranial-bone conduction by noises . . 80 

watch-test 80 

with Politzer's acoumeter 80 

Text-books on ophthalmology 221 

Theories on function of labyrinth 52 

Theory of hearing 49 

Thermophore, use of, in acute mastoidi- 
tis 174 

and ice-bag, use of, in inflammation of 

concha 115 

Thoracic form of pyaemia 320 

Thrombophlebitis 309 

Thrombosis 299, 304 

of sigmoid sinus 273, 314 

Thrombus 304 

Tinnitus 262 

aurium 404 

Titillation 230 

Tonsillar sarcoma 364 

Tonsillitis 155 

Tonus labyrinth 52 

Toothpicks in ear 117, 128 

Topography of internal ear 44 

of the middle ear 26 

Total deaf-mutism 243, 246 

suppuration of mastoid process 206 

Toxaemia 319 



Trabeculse 224 

Tracheotomy in sarcoma of ear 364 

Transillumination of mastoid 172 

Transplantation of epidermis 207 

Transtympanic electro-ionization 233 

direct method 233 

indirect method 233 

Trauma 108, 213, 214 

Traumatic hsematoma 283 

injuries of tympanic membrane 128 

of organ of hearing 361 

injury to labyrinth 269 

meningitis Ill 

Treatment of acute suppuration of mid- 
dle ear 156 

of congenital atresia 105 

antrotomy 105 

artificial auditory canal 105 

with Finsen light in lupus 391 

of otitic thrombophlebitis 310 

of tears and cuts 113 

Trigeminal ganglion 212 

Trigonum digastricum 219 

Trochlearis 269 

Trunk reaction of Ewald 92 

Tubercle bacilli 359 

Tuberculin injection in tuberculous mid- 
dle-ear suppuration 396 

Tuberculosis , ... 113, 159, 168, 207 

of cervical vertebral column 290 

of lobule 390 

of mucous membrane 395 

Tuberculosus osteoperiostitis 179 

Tuberculous abscesses 167 

affections of middle ear 393 

diseases of ear 389 

infections of internal ear 399 

inflammation of cartilaginous integu- 
ment 392 

meningitis 224, 293 

middle-ear suppuration 180, 397 

general invigorating treatment 397 

valuable adjuvant is local applica- 
tion of light 397 

osteoperiostitis of zygomatic process 

or squama 280 

otitis externa 392 

perichondritis 389, 392 

suppuration of labyrinth 399 

Tumor of auditory nerve 352, 353 

of superior maxilla 135 

Tumors 10S 

of bone and cartilage of external audi- 
tory meatus 109 

cerebellar 352, 353 



430 



INDEX 



PAGE 

Tumors of cervical vertebral column . . . 290 

congenital 195 

demarcated 227 

malignant 211 

of middle ear 109 

of parotid 109 

pharyngeal 135 

of superior maxilla 109 

Tuning-fork, lower acoustic limit of . . . . 48 

upper acoustic limit 48 

test 69, 192 

clinical test methods 70 

compass of sounds 70 

intensity of sounds 70 

Turpentine 120 

Tympanic antrum of middle ear 28 

blood-vessels 134 

cavity, fundus of 8 

otoscopy of 56 

changes 279 

membrane 388 

division into quadrants and circular 

sections 57 

increased translucency of, due to 

atrophy 57 

Tympanum of middle ear 15 

Typhoid 152, 308 

Ulceration of labyrinth Ill 

of mucous membrane 222 

of temporal squama 194 

Umbilicus 121 

Umbo 57 

Uncomplicated acute otitis 214 

cases of acute otitis media 308 

. suppuration of labyrinth 268 

Under-nutrition 125 

Ung. diachylon simplex 124 

Unilateral atresia 106 

deafness, demonstration of 80 

facial paralysis 214 

Untreated syphilis 121 

Upper semicircular canal 224 

Uranoschisis 135 

Valsalva's test in rupture of tympanic 

membrane 130 

Varicella 159 

Varioloid erythema 388 

Vena facialis communis 302, 317 

jugularis 302 

Vena? condyloidese 302, 315 



PAGE, 

Venous thrombosis 286 

Ventral otogenic paralysis 211 

Ventricular puncture in otitic meningi- 
tis 360 

Vertex , . 174 

Vertical nystagmus. 86 

Vertigo 87, 171, 209, 266 

cerebellar 89 

labyrinthine 88 

objective 88 

tabetic 88 

Vesicles in eczema 121 

Vestibular apparatus, functional exami- 
nation of 86 

methods of testing 93 

cistern 228 

cul-de-sac 241 

disturbance of gait 95 

of equilibrium 93 

window 212 

Vibratory massage 145, 146 

Vicarious function of ramuli of motor 

trigeminus 220 

Vioform, use of, in affections of ear . 124, 127 
Violent paroxysm of rotatory vertigo. . . 261 
Vomiting 131, 159, 171, 262, 274 

Wheelwrights, deaf-mutes become 250 

Whispering, hearing test by 69 

Window of cochlea 204 

Wire in ear 128 

Wood or glass splinters in ear 120 

Wood-carving taught deaf-mutes 250 

Word-deafness 342 

Writing letters and business documents, 
deaf-mutes taught 250 

Xeroform, use of, in affections of ear . . . 127. 

gauze, use of, in antrotomy 120 

X-ray examination 173 

in cerebellar abscess 353 

in pysemic metastases 322 

in suppurative gummata in squama 

of temporal bone 282 

photography 199 

in sarcoma of ear 364 

treatment in eczema. . 125 

Zahlzelle 49 

Zygomatic process 194 

Zygomatico-oculo-nasal line 215 



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